C H AL L E N G E S I N T H E M AN AG E M E N T O F D R U G S U P P L Y I N

P U B L I C H E AL T H C AR E C E N T R E S I N T H E S E D I B E N G D I S T R I C T ,
G AU T E N G P R O V I N C E

Masters in Science (Medical) in Pharmacy

With Dissertation

S H AM I M A T A Y O B

200818356

Supervisor: Ms EA Helberg

Co-supervisor: Dr S Bezuidenhout

University of Limpopo, Medunsa Campus

School of Health Sciences

Department of Pharmacy

2012
ACKNOWLEDGEMENTS

I gratefully acknowledge and thank:

 My supervisor Ms. EA Helberg and my co-supervisor Dr S.

Bezuidenhout for their ongoing support, motivation and
supervision.

 The statistician Professor Schoeman who assisted with the

analysis of the data.

 The Gauteng Department of Health, Sedibeng district for

authorising this study.

 The clinic staff for their co -operation and willingness in

completing the questionnaire.

 The drivers from the transport department in the completion

of the questionnaire.

 Ms. Priya Bawa for capturing of the data and assisting in

editing the document.

 Mr. Johan van Niekerk and Ms. Meliza Coetzee for their
assistance in the data collection.

i
D E C L AR A T I O N

I, Shamima Tayob hereby declare that the work on which this

research is based is original (except where acknowledgements
indicate otherwise) and that neither the whole work nor any part of it
has been, is being, or is submitted for another degree at this or any
other university.

____________________________

Shamima Tayob

ii
 CONTENTS

ACKNOWLEDGEMENTS ......................................................... i

D E C L AR A T I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i i

LIST OF FIGURES................................................................ xi

L I S T O F T AB L E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x i v

L I S T O F AP P E N D I C E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x v

L I S T O F AB B R E V I AT I O N S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x v i

A B S T R AC T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x v i i i

C H AP T E R 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 INTRODUCTION................................................... .1

1.2 BACKGROUND..................................................... .3

1.3 RATIONALE FOR THE STUDY.................................3

1.4 RESEARCH QUESTION..........................................6

1.5 PURPOSE OF THE STUDY..................................... .6

1.5.1 Aim of the study....................................... ..9

1.5.2 Objectives of the study.............................. .9

1.6 THE SIGNIFICANCE OF THE STUDY...................... .10

C H AP T E R 2 : L I T E R AT U R E R E V I E W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2

2.1 INTRODUCTION........................................... ..12

2.2 AVAILABILITY AND ACCESSIBILITY OF

iii
 AFFORDABLE QUALITY ESSENTIAL

MEDICINES.................................................. .26

2.3 AVAILABILITY OF A SUFFICIENT NUMBER OF

QUALIFIED HUMAN RESOURCES......................26

2.4 AVAILABILITY OF ADEQUATE INFRASTRUCTURE

ACCORDING TO GUIDELINES AND NORMS ........30

C H AP T E R 3 : M E T H O D O L O G Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5

3.1 STUDY DESIGN..............................................35

3.2 SETTING...................................................... .35

3.3 STUDY SITE..................................................36

3.4 STUDY POPULATION......................................36

3.5 SAMPLE SIZE................................................37

3.6 PILOT STUDY................................................37

3.7 DATA COLLECTION........................................38

3.8 DATA ENTRY............................................... ..42

3.9 STATISTICAL ANALYSIS..................................43

3.10 ETHICAL CONSIDERATIONS.............................43

3.11 RELIABILITY AND VALIDITY OF THE STUDY .......44

3.12 BIAS........................................................ .....44

3.13 LIMITATIONS OF THE STUDY............................... .45

C H AP T E R 4 : R E S U L T S AN D D I S C U S S I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 6

4.1 HUMAN RESOURCES.............................................46

iv
 4.1.1 Staff member responsible for drug supply
management.................. ........................................46

4.1.2 Nursing staff trained in dispensing....... ..........49

4.1.3 Availability of a dispensing license according to

the researcher checklist..........................................50

4.1.4 Learner basic and post -basic pharmacist

assistants trained in dispensing...............................51

4.1.5 Training in Drug Supply Management..... .........53

4.2 INFRASTRUCTURE AND SECURITY..................... ...54

4.2.1 Storage area of medicines...........................54

4.2.2 Condition of store room...............................57

4.2.3 Secure delivery area. ............................. .....59

4.2.4 Protection of medicine from direct sunlight....60

4.2.5 Pest infestation........ .............................. ....62

4.2.6 Access control.................... ........................63

4.2.7 Security of the medicine room.................. ....63

4.3 STORAGE AND CONTROL PROCESSES..................64

4.3.1 Delivery and receipt of medication............ ....64

4.3.2 Checking of stock according to transport

officers in the presence of security officers......... ......67

4.3.3 Packing of stock in the medicine store and

the consulting room............................................... .72

v
 4.3.4 Ventilation and temperature control
within facilities.................................................. ....74

4.3.5 Cold chain management.......................... .....77

4.4 MEDICINE MANAGEMENT AND PROCESSES.......... ..80

4.4.1 Inventory system used........................... ......80

4.4.2 Availability of bin cards.......................... .....80

4.4.3 Method of calculating ordering quantities. ......81

4.4.4 Re-order levels........ .............................. .....82

4.4.5 Calculation of re -order levels.......................82

4.4.6 Quantity and period of stock out at clinics. ....85

4.4.7 Responsibilit y for ordering of medication... ....87

4.4.8 Expired medication and tracking of expiry

dates................................................................... .87

4.4.9 Stock take.............. ............................... .....90

4.4.10 Delivery of medicatio n............................. ....95

4.4.11 Response to patients on medication

stock outs.............................................................97

4.4.12 Feedback from district pharmacy............. ......98

4.4.13 Availability of documentation and ordering

processes.................................. ...........................98

4.4.14 Reasons for out of stock situations....... .........98

4.4.15 Standard operating procedures and

reference material... ..............................................102

vi
C H AP T E R 5 : S U M M AR Y O F R E S U L T S AN D C O N C L U S I O N . . . . . . . 1 0 4

5.1 HUMAN RESOURCES...........................................104

5.2 TRAINING OF NURSES AND PHARMACIST

ASSISTANTS.......................................................105

5.3 INFRASTRUCTURE AND SECURITY.......................107

5.3.1 Storage area of medication...........................107

5.3.2 Condition of medicine store................... .......108

5.3.3 Availability of a secure delivery area.... .........108

5.3.4 Protection of medicine from direct sunlight....108

5.3.5 Pest infestation................................. ..........109

5.3.6 Access control and security in the medicine

store............................. ............................. ..........109

5.3.7 Delivery and receipt of medication....... ..........110

5.3.8 Checking of stock according to transport

officers in the presence of security officers..............111

5.3.9 Cold chain management..................... ..........111

5.3.10 Arrangement of medication in the store room

and the consulting room......... ................................112

5.4 MEDICINE MANAGEMENT AND PROCESSES.........11 3

5.4.1 Availability of bin cards...................... ..........113

5.4.2 Method of calculation of drug ordering

quantities........................................................ .....114

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 5.4.3 Availability of tracer and non -tracer
items............................ .......................................115

5.4.4 Stock take........................................ ..........115

5.4.5 Responsibility for ordering of medication. .......116

5.4.6 Expired stock........ ............................. .........116

5.4.7 Delivery of medication....................... ...........116

5.4.8 Visit by the district pharmacists.......... ...........117

5.4.9 Availability of SOP’s and standard reference

material................................ ................................117

C H AP T E R 6 : K E Y R E C O M M E N D AT I O N S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 4

6.1 HUMAN RESOURCES................. ..........................124

6.1.1 Training.............. ............................. ..........124

6.2 INFRASTRUCTURE AND SECURITY.......................125

6.2.1 Storage of medication and condition of a

medicine store and a secure delivery area.... ............125

6.2.2 Temperature control in the medicine store

and consulting room......... ......................................126

6.2.3 Pest infestation......................... ..................126

6.2.4 Access control and security in the medicine

store................................ ............................. .......126

6.2.5 Delivery and receipt of medication.. ...............127

6.2.6 Cold chain man agement................... ............128

viii
 6.3 MEDICINE MANAGEMENT AND PROCESSES..........128

6.3.1 Inventory control systems.............................128

6.3.2 Availability of bin cards...................... ..........129

6.3.3 Method of calculation of drug ordering

quantities....................... .................... ..................129

6.3.4 Availability of tracer and non -tracer items......129

6.3.5 Stock take............................... ...................130

6.3.6 Responsib ility for ordering medication.. .........130

6.3.7 Expired stock................................... ...........131

6.3.8 Feedback from the district............................131

6.3.9 Visits by the district pharmacists......... ..........131

6.3.10 Availability of SOP’s and standard reference

material........................................... .....................132

LIST OF REFERENCES........................................................ .135

APPENDICES........................................... .......................... ..146

ix
 LIST OF FIGURES

Figure 2.1: Typical logistic cycle of DSM performed in the

Sedibeng district........................................ ....15

Figure 2.2: Scope of practice of different categories of

PA’s as performed in the Sedibeng district....... .28

Figure 4.1: Percentage of clinics that rely on specific individuals

for drug supply management (N=25)..................46

Figure 4.2: Number of clinics with nurses trained in DSM

(N=25)........................................ ...................53

Figure 4.3: Stock on the floor (Clinic A)................... ..........55

Figure 4.4: Milk powder stored in the medicine room leading to

unauthorised access to the area and contributing to

a shortage of space (Clinic B )..........................56

Figure 4.5: Cracks in medicine store wall at a clinic

(Clinic C)....................................................... 58

Figure 4.6: Broken ceiling panel ( Clinic D).........................59

Figure 4.7: Availability of secure delivery area ...................59

Figure 4.8: Blinds protect medication from direct sunlight

(Clinic B)........................ ..................... ..........61

Figure 4.9: No protection from sunlight at other clinics

(Clinic E).................................................. .....61

x
Figure 4.10: No protection from sunlight, no electricity in store

room (Clinic C).............................................. .61

Figure 4.11: Dead insects in light cover (Clinic D)................62

Figure 4.12: Lack of security-medicines easily accessible

(Clinic E).......................................................6 4

Figure 4.13: Checking of stock after receipt thereof according

to the questionnaire ( N=25)..............................66

Figure 4.14: Typical type of a ir-conditioner present in the

17 clinics with air-conditioners (Clinic F)...........74

Figure 4.15: Availability of updated temperature charts in the

medicine store and consulting rooms (N=25)......76

Figure 4.16: Ice thicker than 5mm in fridge ( Clinic E)............78

Figure 4.17: Evidence of re -order levels (N=25)....................83

Figure 4.18: Period of tracer items out of stock at clinics

(N=25)........................................................... 86

Figure 4.19: Medication out of stock (Clinic B)...................... 87

Figure 4.20: Damaged and expired medication (Clinic E).......88

Figure 4.21: Medication packed according to FEFO and incidence

of expired stock in the past 12 month s (N=25)...89

Figure 4.22: Evidence (a) and frequency (b) of stock take

(N=25)...........................................................90

Figure 4.23: Unopened stock stored on the floor ( Clinic B)....93

xi
Figure 4.24: Lead time between request and receipt of drugs

(a) and receipt of orders (b).............................95

Figure 4.25: Process followed if facility is out of medication

(N=25).................................. .........................97

Figure 4.26: Insufficient space and lack of shelving

(Clinic B).................................................... ...100

xii
 LIST OF TABLES

Table 4.1: Differences in the number of trained, untrained and

in-training nurses in dispensing (N=208)................49

Table 4.2: Differences in the number of trained, untrained and

in-training pharmacist assistants in dispensing

(N=21).................................. .............................51

Table 4.3: Percentage of clinics employing a specific method of

protection from sunlight (N=25).......................... ...60

Table 4.4: Relevant person/s responsible for receiving stock in

the clinics (N=39)................................................ 65

Table 4.5: Presence of security officers during the receipt of

medication according to the transport

officers (N=4)..................................................... 67

Table 4.6: Persons responsible for receiving stock according to

the transport officers (N=10)...................... ..........68

Table 4.7: Ventilation and temperature control systems

(N=25)................................................................ 74

Table 4.8: Cold chain management (N=25).............................77

Table 4.9: Delivery of medication according to transport

officers (N=4)................................................... ..96

Table 4.10: Percentage of clinics with the relevant

available SOP (N=25).......................................... 102

xiii
 LIST OF APPENDICES

APPENDIX 1: PARTICIP ANTS’ CONSENT FORM ..............146

APPENDIX 2: INFORMED CONSENT FORM...........................148

APPENDIX 3: Q U E S T I O N N AI R E - T R AN S P O R T O F F I C E R . . . . . . . 1 5 0

APPENDIX 4: Q U E S T I O N N AI R E -
S T O R E M AN AG E R / F AC I L I T Y M AN A G E R . . . . . . . . . . 1 5 1

APPENDIX 5: R E S E AR C H E R C H E C K L I S T . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 5 6

APPENDIX 6: T R AC E R M E D I C I N E L I S T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 5 8

APPENDIX 7: G L O S S AR Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 5 9

APPENDIX 8: CLINIC SUPERVISORY TOOL..........................170

APPENDIX 9: E T H I C AL C L E AR A N C E C E R T I F I C AT E . . . . . . . . . . . . . . 1 7 6

A P P E N D I X 1 0 : S T O C K C AR D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 7 7

A P P E N D I X 1 1 : D A T A S H E E T – S E C T I O N A:
F A C I L I T Y M AN AG E R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 7 8

APPENDIX 12: DAT A SHEET – SECTION B:

I N F R AS T R U C T U R E & S E C U R I T Y . . . . . . . . . . . . . . . . . . . . . 1 8 2

APPENDIX 13: DAT A SHEET – SECTION C:

S T O R AG E & C O N T R O L P R O C E S S E S . . . . . . . . . . . . . . . 1 8 5

APPENDIX 14: DAT A SHEET – TRANSPORT OFFICERS ...........197

xiv
 L I S T O F AB B R E V I AT I O N S

ARV Anti-retroviral

CHC Community Health Centre

DOH Department of Health

DSM Drug Supply Management

EDL Essential Drug List

FEFO First expired - First out

FIFO First-in/first-out

FM Facility Manager

GDOH Gauteng Department of Health

GPP Good Pharmacy Practice

HIV Human Immune-deficiency Virus

HST Health Systems Trust

MEC Member of the Executive Council

MSD Medical Supplies Depot

xv
NCS National Core Standards

NDOH National Department of Health

NDP National Drug Policy

PA Pharmacist Assistant

PHC Primary Health Care

ROL Re-order Level

S A AH I P South African Association of Hospital and Institutional

Pharmacists

S AP C South African Pharmacy Council

SOP Standard Operating Procedures

STG Standard Treatment Guidelines

STI Sexually Transmitted Infection

TB Tuberculosis

WHO World Health Organisation

XDR-TB Extensively drug resistant Tuberculosis

xvi
 AB S T R A C T

In South Africa, 80% of the population is dependent on the

government to provide for their health care needs, mainly

through primary health care facilities. In the health objectives

of the National Drug Policy, the government of South Africa

outlines its commitment to ensuring availability and

accessibility of medicines which are effective, affordable, safe

and of good quality in all sectors of the health care system

(National Department of Health, 1996).

In order to assess the availability of drugs and identify

challenges which exist in the Emfuleni sub-district within the

Sedibeng district, a questionnaire was administered to 21

primary health care facility managers/store managers, four

Community Health Centre managers and five transport officers

in the district.

In addition, a document review process was conducted to verify

aspects of the facility managers’ and store managers’

responses. Bin cards and primary health care order files were

also examined in conjunction with a checklist to establish

whether stock control systems were in place.

xvii
There was a 100% response with all primary health care centres

and community health care centres completing the

questionnaires. It was established that drugs at primary and

community health care clinics were procured from the Sedibeng

district pharmacy.

In each of these clinics there were specific individuals

responsible for medicine supply management. Only four primary

health care clinics had full-time pharmacist assistants

employed, and 14 clinics were visited by the assistants on a

weekly/bi-weekly basis. There were no employees that have

received training in drug supply management in the last 12

months in 88% of the clinics interviewed.

Nineteen clinics claimed that the storage area was not large

enough to store all the stock for a month’s supply and only one

clinic had a secure delivery area for their medication.

It was established that 24 facilities received stock by two

specific procedures namely; that the number of boxes were

checked and the driver’s note was then signed, and stock

received was checked against the invoice. Of the interviewed

xviii
clinics, 20% admitted that the re-order level had not been

calculated for all tracer items in the store .

Standard Operating Procedures, Standard Treatment Guidelines

and the Essential Drugs List were also not available at all

facilities. The results indicate inadequacies and weaknesses in

procurement, quantification, stock control, storage and record

keeping.

It clearly demonstrates that inadequately-trained staff was a

major contributing factor to drug shortages. There was a lack of

monitoring and evaluation by the district pharmacy as

pharmacists did not manage to visit all the clinics each month.

Most of the inadequacies and weaknesses can be addressed at

facility level with proper supervision, in-service training,

mentoring and support of staff and the reinforcement of drug

supply management training.

Regular supervisory visits together with updating the monitoring

tool in terms of the problems identified will improve the

management of drugs and ultimately decrease the number of out

of stocks where problems have been identified at primary health

care level.

xix
 C H AP T E R 1

1.1 INTRODUCTION

According to the W orld Health Organisation (W HO) standards,

essential drugs are those drugs which the nation must have in

sufficient quantities at all times for the management of the most

common ailments that afflict the greater number of its

population (W HO, 1998). The Essential Drugs List (EDL)

program is derived from this concept. It is understandable that

the essential drug classification is unique to each country as

what may be regarded as non-essential in one country may be

essential in another country due to each country’s disease

patterns and level of develop ment (Jha & Roy, 2005).

Although medicines are one of the vital tools needed to improve

and maintain health, for too many people throughout the world

medicines are still unaffordable, unavailable, unsafe and

improperly used. An estimated one third of the world’s

population lacks regular access to essential drugs, with this

figure rising to over half in the poorest parts of Africa and Asia

(Chetley, Hardon, Hodgkin, Healand & Fresle, 2007).

1
According to Dukes and colleagues, the following factors may

impede drug supply management (DSM), (Dukes, Garnett,

Hogerzeil, Laing, O’Connor, Quick & Rankin, 1997):

 The lack of infrastructure for st orage and distribution of

drugs

 The lack of dedicated transport to ensure constant drug

supply

 Losses from expiration, theft, fraud and inappropriate

storage

 Inaccurate forecasting of drug requirements due to non -

adherence to drug re-order levels (ROL).

At the Primary Health Care (PHC) level, factors affecting usage

would be determined by prescription patterns, patient

adherence, drug availability and patient load. Other factors

which impact on the usage are inventory control and the

availability of human resources (Dukes et al., 1997).

Many of the factors indicated above are common to the current

public sector in terms of DSM. Medicine expenditure in most

developing countries represents one to two thirds of the total

public and private health expenditure. It is therefore important

to identif y challenges which exist in terms of DSM (W HO, 1998).

2
1.2 B AC K G R O U N D

In South Africa, many districts have reported that district health

facilities (mostly PHC facilities) do not have essential drugs in

stock (Matse, 2005a). W ithin a decade after the first modern

pharmaceuticals became available, efforts began to ensure their

widespread availability. From the mid 1950 ’s to the mid 1970’s,

basic management concepts began to evolve in countries such

as Norway, Papua Guinea, Sri Lanka, Cuba and Peru (Matse,

2005a).

Availability of medicines has been shown to enhance the

utilisation of health facilities and the reputation of health

professionals and the entire health care system in general.

Gray and co-workers reported that many patients view access to

drugs as an indication of good health care management (Gray,

McCoy & Suleman, 1988). The country’s socioeconomic contrast

poses a unique challenge to the National Department of Health

(NDOH) to make cost-effective healthcare accessible to all the

inhabitants of the country.

1.3 RATIONALE FOR THE STUDY

According to the Management Sciences for Health, “most

leading causes of discomfort, disability, and premature death

3
can be prevented, treated or at least alleviated with cost

effective drugs” (Matse, 2005a). According to the National Drug

Policy (NDP) of 1996, drugs have bestowed enormous health

benefits on people all over the world (NDOH, 1996). They have

transformed the treatment and prevention of many diseases,

thus resulting in many lives being saved from death and a

greater improvement of the quality of life of others (NDOH,

2003).

Research has proven that essential drugs have a major impact

on common causes of morbidity and mortality. The huge burden

of illness due to acute respiratory infections, diarrhoeal

diseases, measles, malaria, sexually transmitted infection’s

(STI), tuberculosis (TB), chronic diseases and other illnesses

can be substantially reduced if essential drugs are available

and properly utilised (Ohuabunwa, 2008).

There is no doubt therefore that whilst it is important to invest

in prevention through health education and other programs to

improve nutrition, sanitation, water supply, housing,

environment and personal hygiene, the availability of essential

drugs in response to many diseases is also of importance (Gray

& Suleman, 2009).

4
Despite all these benefits, drugs have not been available to all

South Africans. This has been the case even after the NDP and

the essential drugs program were adopted to ensure that

essential drugs are available at all times, in adequate

quantities and in the appropriate dosage forms. It has already

been mentioned earlier that many district health facilities do not

have drugs in stock (Davids, Mbelle, Mohlala, Peltzer,

Phaswana-Mafuya, Ramlagan & Zuma, 2006).

A study by the Health Systems Trust (HST) found that the

Kgalagadi district of the Northern Cape had a problem of drug

shortages. Reasons for these shortages were not identified

(HST, 2003). Also participants of a drug management workshop

held in Tzaneen (Mopani district) admitted that their respective

health facilities faced serious shortages of essential drugs. The

workshop was held in August 2002 and all participants were

drug managers at their respective health facilities. However,

the reasons behind these shortages were not determined

(Davids et al., 2006).

Since the determinant factors associated with essential drug

shortages in PHC facilities are based on the political, cultural,

and economics of a specific district, reasons for drug shortages

5
may vary from district to district. Therefore, this study aims to

outline the factors associated with essential drug shortages in

PHC facilities specifically in the Sedibeng district.

1.4 R E S E AR C H Q U E S T I O N

What are the challenges experienced in the management of drug

supply in PHC centres in the Sedibeng district in Gauteng?

1.5 PURPOSE OF THE STUDY

In the Gauteng Province, drugs which are out of stock at the

district pharmacies are reported to pharmaceutical services on

a weekly basis (an out of stock item results, when the demand

for an item cannot be fulfilled from the current inventory).

According to circular 39 of 2005 issued by the Gauteng

Department of Health (GDOH) a norm of not more than two

percent of drug “stock outs” is acceptable (GDOH, 2005).

Effective pharmaceutical procurement and distribution

processes are essential to ensure the availability of drug

supplies. Pharmaceutical services in the Gauteng Province have

developed a procedure manual and a set of standard operating

procedures (SOP’s) for DSM to ensure an effective system of

monitoring and evaluation. Over the last 20 years different

6
countries have acquired considerable experience in managing

drug supply. Broad lessons which emerge from this experience

include that:

 The NDP provides a sound foundation for managing drug

supply,

 Wise drug selection underlies all other improvements,

 Effective management saves money and improves

performance and,

 Systemic assessment and monitoring are essential.

What works best in DSM has no simple answer. Each country

brings unique political, economic and geographical factors to

the equation. In addition, to weigh one drug supply system

against another cannot be properly done from a global

perspective without a detailed study (W HO, 1998 ). However,

what the experience of countless countries does demonstrate is

that substantive and sustainable improvements in the supply

and use of drugs is possible, but an equal or greater number of

negative experiences show that success is by no means

assured. Clear goals, sound plans, effective implementation and

monitoring are essential ingredients in the pharmaceutical

sector development (W HO, 1998).

7
Unless changes in drug supply systems are based on careful

analysis of the underlying causes for the weaknesses of the

existing system, a change in the system is unlikely to prod uce

the desired outcome. Systems that are chosen because they

function in a “successful” market economy may not prov e to be

the solution to the drug supply problems faced in the context of

a developing country (W HO, 1998).

However, in recent months, complaints were made directly to

the Member of the Executive Council (MEC) for Gauteng health

by patients in the Sedibeng district, with regards to the non-

availability of drugs at PHC level, which has increased in the

Gauteng Province. Under the directive of the MEC for GDOH,

monitoring and evaluation teams have been established to

ensure drug availability of 99.5% stock levels at all times in

accordance with circular minute 118 of 2009 (GDOH, 2009).

In line with these patient complaints the Sedibeng district has a

challenge to determine reasons for drug “stock -outs” at their

PHC facilities. There is thus an urg ent need to carefully review

DSM in order to determine the problems associated with it.

Furthermore, a study in terms of factors affecting DSM or any

8
related study has never been previously conducted in the

Sedibeng district.

1 . 5 . 1 Ai m o f t h e S t u d y

The aim of this study was to determine problems or challenges

affecting DSM at PHC level in the Sedibeng district.

1.5.2 Objectives of the Study

The specific objectives of this study were as follows:

1. To establish the availability of trained personnel to

manage drug supply,

2. To explore the availability of infrastructure to store drugs

at PHC level according to Good Pharmacy Practice (GPP)

requirements,

3. To study the distribution process in terms of availability

and accessibility of drugs at PHC level ,

4. To identify if stock control systems were in place to ensure

affordable and acceptable drugs at PHC level ,

5. To update the current tool to effectively monitor drug

supply in the Sedibeng district. A monitoring and

evaluation tool is currently used from the clinic supervisors

manual (DOH, 2003), to monitor DSM in the Gauteng

Province.

9
1.6 THE SIGNIFICANCE OF THE STUDY

The significance of the study is to establish a detailed appraisal

of the drug procurement process and inventory control system

within the Sedibeng district. The results from the study will also

assist in:

 Identifying challenges which exist within the Sedibeng

district which will assist in addressing shortcomings in

terms of the DSM cycle,

 Providing a baseline of performance against which

subsequent quality improvements can be measured,

 Updating the current monitoring tool in order to improve

future monitoring and evaluation processes,

 Enhancing the capacity and skills of participants at PHC

level in DSM,

 Ensuring compliance with the National Core Standards

(NCS) in terms of patient care and the availability of

medicines (DOH, 2011),

 Providing recommendations for improving the functioning of

DSM not only at a local level but which are generic to the

improvement of DSM around the Gauteng Province .

10
This chapter summarised the importance of the availability of

essential drugs at PHC level. It also outlines the aim and

objectives of the study and highlights the significance of the

study. The subsequent chapter introduces a broad overview of

the DSM cycle and highlights the d ifferent aspects linked to

procurement processes.

11
 CHAPTER 2

LITERATURE REVIEW

2.1 INTRODUCTION

Drugs have a special importance and need to be available for

the following reasons:

 Drugs save lives and improve health outcomes,

 Drugs promote trust and participation in health services,

 Essential drugs provide a direct low cost response for

many diseases (Dukes et al., 1997).

Considering these brief reasons for the importance of the

availability of drugs, it is imperative that the management of

drug supply follows a stringent process. Therefore, t he general

management function requires an examination of the

management process as a whole, in particular the planning and

organisation that is required by management . This must include

leadership and control, which managers have to exercise over

processes, in order to effectively implement plans (Booyens,

1997).

General management embraces the overall function, through

which top management develops strategies and formulates

12
policies for the entire organisation (Booyens, 1997). One such

policy which is currently under review is the NDP which

provides a sound foundation for managing drug supply. The NDP

(1996) within the framework of the National Health Policy aims

to improve access to health service, through ensuring the

availability of appropriate drugs whenever they are needed

(Dukes et al., 1997).

The management of drug supply is organised around the four

basic functions of the DSM cycle namely: selection,

procurement, distribution and use. At the centre of the DSM

cycle is a core of management support systems, which include

organization, financing and sustainability, information

management and human resource management (Dukes et al.,

1997).

The success of the DSM cycle will depend upon the ability to

reliably and consistently supply the drugs to health facilities at

all levels of the health system (Mohammad & Raja, 2004). The

consequence of supply interruption can be dire, including

antibiotic and anti-retroviral (ARV) drug resistance, which could

have a wider global impact on the availability of drugs for

treatment.

13
Medical health drug supply chains are different because they

usually have large, extended global pipelines, require high

levels of product availability and have a high uncertainty in

supply and demand.

It is therefore paramount that supply chain or logistics systems

are treated as an important and critical function in getting the

drugs to their destination. In fact, in order to sustain and

expand the successful interventions experienced to date, the

supply chains will need to be made more robust, agile and

flexible through better management and increased investment of

resources to achieve supply chain optimization (Mohammad &

Raja, 2004).

The term supply chain describes the links and the

interrelationships among the many organi sations, people,

resources, and procedures involved in getting drugs to patients.

A typical supply chain would include partners from

manufacturing, transportation, warehousing and, service

delivery.

Delivery and distribution of drugs at various levels are not

possible without effective drug procurement and inventory

14
control. DSM tools help managers with the process of

distributing drugs and supplies to clinic facilities and ultimately

to patients, through following a series of steps viz. forecasting

needs, the tender process, ordering, receiving,

storing/warehousing, and distribution (Mohammad & Raja,

2004).

Availability
of
medication Updated bin
cards
Re-order levels

Managerial Supervision Procurement

Staffing-training, budgeting, from district
Distribution supervision, monitoring and according to
evaluation EDL

Infrastructure- Dedicated trained

availability of person to manage drug
shelving supply availability &
Appropriate storage transport
Receipt of
medication

Figure 2.1: Typical logistic cycle of DSM performed in the

Sedibeng district.

15
The procurement of drugs involves various steps including

quantification, sourcing, pricing and ensuring timely delivery to

the central store. The management of inventory depends on

information systems that provide feedback for:

 Tracking the storage and movement of goods at every level

within the supply system and storage of medication ready

for use in health facilities,

 Ensuring proper stock rotation and medicine with dates so

that items of earliest expiry dates are used first, as well as

Enabling managers to know the total amounts of drugs that are

within the supply and where they are located thus allowing the

possibility of redistribution (Mohammed & Raja, 2004).

Inventory records should be regularly updated to confirm that

items are being used correctly and not diverted and misused .

Thus inventory control is essential as a source of data for

review and decision regarding future procurement (Mohammed &

Raja, 2004).

However, despite availability of numerous tools for the

management of drugs, none of these specifically targets the

health worker who has had no formal training in drug logistics

and supply management systems (Jha & Roy, 2005).

16
In health care, ensuring that there are adequate drugs and

supplies for every patient is paramount, as partial or

intermittent treatment can lead to less that optimal results and

in some cases, this can even be disastrous, both for the

individual patient and the public at large (Jha & Roy, 2005).

This concept of full supply is not always applied and many

countries manage drugs supplies by rationing systems.

However, in the case of Human Immune-deficiency Virus (HIV)

treatment, rationing strategies cannot be used and once a

patient is placed on treatment, there must be uninterrupted

supply of drugs. Rationing could easily lead to treatment

interruption and this could lead to treatment failure, drug

resistance and a host of other problems, which would ultimately

have a huge negative global impact. Ensuring full supply of

drugs can be costly and requires additional strategies to

optimise the use of resources (Mohammed & Raja, 2004).

Strategies for improving full-supply are as follows:

 Maximise all sources of funding through better co-

ordination.

 Provide full and continuous treatment to fewer patients.

17
  Partner with manufacturers in providing timely forecasts

and reducing uncertainty in planning and unplanned costs.

 Purchase in bulk to obtain better prices where possible.

 Make the supply chain efficient resulting in fewer

inventories tied in safety stock. This may require

shortening the pipeline and delivering directly to the

service delivery site and not through intermediary

warehouses.

 Reduce loss and pilferage by implementing a security

system across the supply chain.

 Standardise and limit the number of drugs and supplies in

the system.

 Reduce duplicative drugs and supplies.

 Implement an automated logistics information management

system that tracks stock levels and consumption patterns,

making inventory transparent through the system.

 Monitor the use of drugs and supplies (Mohammed & Raja,

2004).

Effective distribution management includes the availability of an

efficient network of storage facilities, keeping reliable records

of drugs stock balance and consumption, maintaining

accountability procedures, ensuring adequate and secured

18
storage, reliable transport systems and reinforcing reporting

and supervisory practices. Matse stated that a third of

procurement and distribution processes are compromised due to

a lack of adequately trained staff. He also stated that “the

professionals who are expected to ensure proper purchase,

utilisation and appropriate use of those drugs often lack basic

knowledge on the management of drug supplies” (Matse, 2005 b).

The HST’s initiative for sub-district support claims that by

ensuring an adequate supply of medicine to clinics is only

addressing half the problem. They further argue that it is also

necessary to address drug use patterns and ensure that drug

use is rational (HST, 2003). Rational prescribing refers to “the

process of making sure that the diagnosis, advice and treatment

for any given patient is correct, and if a medicine is used, that

it is the correct choice and correct dose” (Mohammed & Raja,

2004). Quite often poorly trained prescribers, prescribe

irrationally resulting in drug shortages (H ST, 2003).

For example, in Kenya, Matse determined that inadequately

trained staff members are an important contributing factor to

drug shortages as a result of their irrational prescribing (Matse,

2005b). Other studies attributed drug shortages to drug misuse

19
and abuse by patients who collect treatment even if they are not

sick, or those who accumulate more drugs than they require.

Bakarich and co-workers, for example stated that in the United

States, “hoarding drugs is not an uncommon practice

[especially] among elderly women” (Bakarich, Finucane, Harris

& Healy, 2006).

A study conducted in the Mopani established that none of the

workers understood the method they claimed to use to

determine quantities to be ordered. Whether it was Maximum

and Minimum Stock Order Levels, Consumption -Based ROL or

the Average Monthly Consumption, the workers had no clue how

these formulas were used (Matse, 2005b).As a result the study

concluded that staff relied on their work ing experience to

determine the quantities to be ordered. It was found that almost

thirty percent of the facilities indicated that they had no formal

method of quantifying their orders. The stock outs and

overstocking found in Mopani could mainly be attributed to the

lack of knowledge with regard to quantification method (Matse,

2005b).

Unreliable transport for drug supplies has also been cited as a

major problem in many health care programs in developing

20
countries. Transport is either difficult to p lan and manage, or is

inadequate to health care delivery. Unavailability of reliable

transport systems is a major contributing factor to drug

shortages (Matse, 2005a).

According to WHO, medicines are the second highest expense

after staff costs in a country’s health care system (Matse,

2005a). The World Bank indicates that in many developing

countries, a high percentage of medicine losses occur in the

state procurement, storage, distribution, and utili sation system.

The World Bank also estimates tha t in Africa, the patient

receives only 12 cents out of every dollar spent by the

government on medicines. Inefficiency is the major contributor

to these losses (Matse, 2005a). Out of the 100% budget

allocated for medicines, 10% is lost through inadequate b uying

practices, 14% through quantification problems, 27% through

procurement, 19% through inefficient distribution, 15% through

irrational prescribing, and another 3% through patient non -

compliance. All these losses that occur in the supply chain add

up to 88% of the original budget (Matse, 2005 a).

21
It has also been established that in certain areas a significant

proportion of essential medicines and supplies meant for PHC

are misappropriated or diverted. This diversion is at two levels,

firstly at the district pharmacy drug store level and secondly, at

the PHC level (Matse, 2005b).

Health workers, especially the store managers and those at the

dispensaries, divert some of these items either for personal use

or by outright theft as some of the items d elivered to the health

centres have been found in the open drug markets. This matter

is worsened by poor supervision because in many cases there

are no pharmacists to provide supervis ion and even the other

health care staff to which such duties are assigned are

sometimes negligent or even collude to divert the medicines and

supplies. Similar situations exist in some state medical stores

and general hospitals (Matse, 2005b).

In terms of the drug supply and management system of the

public health sector, the NDOH monitors the ability of suppliers

to supply medicines. During 2009/10, there was a 12% stock out

of the 45 ARV’s on tender. This was measured in 9 provinces

(405 items). There was also a 21.8% stock out of the 35 TB

drugs on tender in the 9 provinces (315 items) (NDOH, 2009).

22
Factors influencing these drug stock outs included: financial

constraints and insufficient budget allocation for

pharmaceuticals at provincial level , suspension of accounts,

and suppliers not adhering to lead times (NDOH, 2009).

During 2009/10, the NDOH secured an additional R900 million

from the national treasury to support provinces with the

acquisition of ARV’s, to ensure that patient care was not

compromised. The NDOH continues to support provinces with

accurate cost estimates for both ARV’s and TB medicines.

However, despite the additional allocation of budget, medicines

continue to be out of stock at PHC levels (NDOH, 2009).

In 2011 the South African Association of Hospital Pharmacists

(SAAHIP) conference focused on the improvement of the quality

of pharmaceutical services in the public sector at PHC’s and

CHC’s with particular emphasis on the management and policy -

making settings. Improving the quality of health care is central

to the NDOH Strategic plan for 2009/2011 and the 10-point plan

of 2009-2014, which highlights the improvement of the quality of

health services provided (Bradley, Johnson, Putter & Von Zeil,

2011).

23
The conference also introduced the NCS and explored the

implications for pharmaceutical services. In terms of the

availability of medicine supplies, the following aspects were

discussed:

 Management of budget and inventory control,

 Development of alternative delivery systems for medicines,

 The need to improve patient education with regard to

medicines which will in turn lead to improved availability

and responsibility for medicine supplies,

 Lack of human resources and the failure to utilise available

human resources optimally (Bradley et al., 2011).

The objectives of the core standards are (Bradley et al., 2011):

 To establish a benchmark against which health

establishments can be assessed, gaps identified, and

strengths appraised,

 To highlight the practical implications of quality

improvement in pharmaceutical services,

 To identify interventions to improve the quality of

pharmaceutical services using the NCS.

The following were suggested to improve standards:

 Identify sites of “best practice”,

24
  Self-assessments (audits) in pharmacies,

 Monitor changes over time,

 Assist in motivations for more resources, including

equipment and staff (Bradley et al., 2011).

The importance of the availability of qualified staff and

appropriate infrastructure is often taken for granted within

government institutions and policy implementation is expected

without appropriate resources.

According to an article published by the World Council of

Churches, the implementation of PHC services requires a

minimum of the following pre -conditions (Ndilta, 2009):

1. Availability and accessibility of affordab le quality essential

medicines,

2. Availability of a sufficient number of qualified human

resources for health,

3. Availability of adequate infrastructure according to

guidelines and norms.

25
2.2 AV AI L AB I L I T Y AN D ACCESSIBILITY OF AF F O R D AB L E

Q U AL I T Y E S S E N T I AL M E D I C I N E S

The main objective of the Essential Drug Program is to achieve

success and equity through effective D SM (Dukes et al., 1997).

An EDL is available in pharmacies in South Africa. District

pharmacies within the Gauteng Province supply drugs to PHC

facilities within their districts according to the EDL. Thus

selection, procurement and distribution of drug supply occur at

the district level. Pharmaceutical services in the Gauteng

Province have developed a procedure manual and a set of

SOP’s, for DSM to ensure an effective system of monitoring and

evaluation. However, drug stocks outs continue to be high

despite the implementation of the above mentioned guidelines.

2 . 3 AV AI L AB I L I T Y O F A S U F F I C I E N T N U M B E R O F Q U AL I F I E D

H U M AN R E S O U R C E S

The quality of health services, their efficacy, efficiency,

accessibility and viability depend primarily on the performance

of those who deliver them. However, research in this area has

been neglected in many countries (Jokhio, Lancashire &

Pappas, 2008). Not unlike other developing countries, South

Africa’s public health system is characterised by human

resource shortfalls (Hall, 2003). Due to the shortage of staff, a

26
process of task-shifting has taken place. In African countries

such forms of “task shifting” have been described as the

indirect substitution or delegation of tasks to an existing but

different profession e.g. from doctors to nurses or pharmacists

(Loffstadt, Schneider, Steyn & Van Rensburg, 2007).

Thus, progress towards the legislation permitting nurses to

prescribe medicines stemmed from the recognition that there

were insufficient prescribers to deal with community health

needs (McGilvray, Miles & Seitio, 2006). The original right of

nurses to prescribe was dealt with in Section 38A of the old

Nursing Act 1978 which has now been amended to section 56A

of the new Nursing Act of 2005 (NDOH, 2006; Kruger, 2009).

Due to registered pharmacists and pharmacist assistants (PA’s)

being a scarce skill, nurses also currently manage drug

supplies at PHC level, with the exception of a few institutions,

where pharmacists and PA’s are available (Loffstadt et al.,

2007).

 PA’s at different levels of training has been placed at PHC

clinics within the Sedibeng district as from June 2011.

27
  The scope of practice of the two categories of PA’s is

explained in the Regulations relating to the practice of

pharmacy published in terms of the Pharmacy Act, 1974, as

amended (SAPC, 2011).

Scope of practice of PA’s:

PA’s perform a wide variety of functions within the various

sectors of pharmacy. Two categories of PA’s can be identified;

viz.

 Basic PA’s; and

 Post-basic PA’s.

DUTIES OF A POST BASIC

ASSISTANT
pick , label, dispense to patient
manufacturing ,cold chain
management , can supervise Post-basic
basic, learner basic and post
basic pharmacist assistants,
under distant supervision

DUTIES OF A BASIC AND

LEARNER POST BASIC
ASSISTANT
Basic Learner post
Compile clinic orders, pick
prescriptions, fill in bin cards
basic
under supervision

DUTIES OF A LEARNER
BASIC ASSISTANT Untrained-
Packing of shelves, assist in
dispatching of orders, filing in
Learner basic administative
bin cards, compiling orders, duties
under supervision

Figure 2.2: Scope of practice of different categories of PA’s as

performed in the Sedibeng district.

28
The scope of practice determines the activities, responsibilities

and accountability of PA’s in the practice setting. However,

PA’s need to have in service training in terms on site in terms

of establishing ROL’s, consumption data, monitoring and

evaluation of drug usage.

In terms of Human and Institutional Resources the strength of a

health commodity supply chain is dependent upon (Mohammad &

Raja, 2004):

 Having assigned staff for logistical functions,

 Ensuring that staff have the capacity to conduct the

logistical functions,

 Having clear logistics job descriptions,

 Providing the tools to the staff to be able to do their jobs,

 Providing clear job aids,

 Providing clear procedure manuals,

 Encouraging and empowering staff to take initiative to

continually improve processes for each of the functions,

 Creating performance measures for the logistics functions ,

 Including timeliness of deliveries, product availability at

health facilities, reduction of loss due to expiry,

 Building and strengthening monitoring and supervision .

29
2 . 4 AV AI L A B I L I T Y O F AD E Q U AT E I N F R AS T R U C T U R E AC C O R D I N G

TO GUIDELINES AND NORMS

Well-located, well-built, organised and secure storage facilities

are an essential component of a drug supply system. A minimum

set of guidelines are set out in GPP as required by the South

African Pharmacy Council (SAPC) in terms of standards at PHC

facilities (SAPC, 2010).

Poor quality of care with inadequate training, inconsistent drug

supplies and limited resources results in poor health outcomes

especially in TB and HIV (The Global Fund, 2010).

South African extreme drug resistant-TB (XDR-TB) patients

moreover, are also showing increased drug -resistance because

these patients are only given two active agents due to 'poor

medication access'. “This (lack of medication access) will

undoubtedly amplify drug resistance" (Stuijt, 2007). It is also

commented that this (growing drug resistance) "may be averted

by accelerating access to second -line agents (drugs) for use in

bolstered regimens"(Stuijt, 2007).

In Nigeria a study was conducted in 2003 on the availability of

ARV’s (W HO, 2003). The objective of this study was to conduct

30
a rapid assessment of the use and management of ARV ’s in

treatment centres. The assessment was aimed at identifying

pressing issues in program management that could hinder the

achievement of ensuring the uninterrupted supply of good

quality ARV’s. In essence, the result of the study was to form

the basis for management decision -making and re-engineering

of the ARV drug programme.

Eighty percent (80%) of the facilities had the three first-line

ARV’s namely, Nevirapine, Stavudine and Lamivudine , in stock.

Forty four percent (44%) of the facilities did not have adequate

stock balance of these three ARV’s and eight (8) facilities had

experienced stock out for periods ranging from one to three

months (W HO, 2003).

Expired ARV’s were found in 64% of the facilities with the loss

due to expiry estimated at $146,717. One of the five

consignments of ARV’s received at the Central Medical Store

had a shelf life of five months (W HO, 2003). Storage of ARV’s

was generally satisfactory in all the cent res as 84% and 92%

scored above the 50% required for adequacy of storage in the

dispensary and the facility store, respectively (W HO, 2003).

31
The goal of an ARV program, which is to provide uninterrupted

drug supply to treatment centres and to patients in a timely

manner, while minimising drug expiry, was not achieved. In fact,

the study revealed poor mana gement of drug supply. There is

thus the need to evolve effective drug procurement,

distribution, financing and ARV information management

systems to improve access and affordability of ARV ’s (W HO,

2003).

Therefore,

 Drug procurement for PHC centres need to be adequately

budgeted for,

 Pharmacists and other appropriate healthcare workers must

be involved in the development of the list of drugs ,

purchase, storage, distribution and dispensing of the drugs

and necessary supplies,

 Proper record keeping must be establ ished with adequate

supervision,

 Regular financial audits must be undertaken to ensure cost

effective utilisation of the drugs and supplies and

additional outcome audits must also be undert aken to

assess impact on the health of the community,

 The health care workers that manage drug supply must be

trained and equipped to carry out the very basic but very

32
 essential service of managing drugs and monitoring supply

to ensure continuous availability (Ohuabunwa, 2008),

 A high level Enlightenment Campaign must be undertaken

to achieve the following:

1. Bringing of health consciousness among the people,

2. Teaching simple ways of keeping healthy,

3. Inviting people to visit the PHC centre, indicating the

locations and assuring that health care professionals

are on duty and that there are sufficient drugs ,

4. Preparing people to adopt preventive measures

before the outbreak of epidemics such as meningitis.

It is medicines that make health care delivery credible. Many

people who go to health institutions and see the best doctors or

undertake the most rigorous tests and investigations go home

unhappy if they do not have medicines prescribed or

recommended for them (Ohuabunwa, 2008).

It is therefore critical that any health care system must take the

issue of making quality drugs and essential hospital

consumables available in the right quantities and correct pricing

structure. It becomes even much more important in the PHC

service set up. It is here that the disease progression must be

stopped and people enabled to return to work speedily. In

33
addition, it is here that the expectation of the people to take

drugs home after a visit is highest and it is here in many cases

that the people cannot afford to pay for expensive medicines or

other high hospital cost (Ohuabunwa, 2008).

In this discourse it has been identified that poor and inadequate

budgetary allocation, diversion of products, poor value for

money, uncoordinated governmental actions and the local

unavailability of quality essential medicines constitute the

major challenges affecting the sustained availability of

essential medicines and supply for PHC services (Ohuabunwa,

2008).

The above information dealt with DSM and the reasons for drug

stock outs found in other studies. This study will specifically

deal with stock outs in the Sedibeng district in order to ensure

99.5% availability of drugs at a ll times as requested by the

NDOH, Gauteng.

34
 C H AP T E R 3

M E T HO DO LO G Y

3.1 STUDY DESIGN

A retrospective, quantitative, descriptive cross -sectional

approach was followed over a three month period . This study

design was followed to essentially ensure that the data acquired

for the study could be quantitatively evaluated, compared and

measured so that quantitative postulations could be made.

Furthermore, a descriptive approach was followed so that the

data acquired could be analyzed in a systematic manner with

the use of tables, figures and graphs. In consideration of the

time constraints and for the standardization of the data

acquisition process a cross-sectional and retrospective design

was followed. Thus, data was acquired either through

past/current records over a defined period of time where data

may have been collected for other purposes.

3.2 SETTING

The Gauteng Province is divided into three different regions

based on geographic location namely,

 Region A consists of the City of Johannesburg and W est

Rand (Mogale City) districts,

35
  Region B consists of the Ekurhuleni and Sedibeng districts,

 Region C consists of Tshwane and Metsweding districts.

Region A, B and C are provincial health districts. However, the

city of Johannesburg, Ekurhuleni and Tshwane also have

municipal metropolitan areas.

A central Medical Supplies Depot (MSD) provides drugs to each

district. Drugs are also procured directly from various

companies through MSD. Furthermore, each district has a

district pharmacy which supplies drugs to PHC clinics and

CHC’s within the specific district. This study wil l be conducted

in the Sedibeng district where there are three sub -districts

which are Lesedi, Midvaal and Emfuleni.

3.3 STUDY SITE

The study was conducted in the Sedibeng district, in particular

one of the three sub-districts namely, Emfuleni.

3 . 4 S T U D Y P O P U L AT I O N

There are a total of 34 PHC clinics and 4 CHC’s in the Sedibeng

district. For the purposes of this study, the largest sub-district

which consists of the 4 CHC’s and 21 PHC clinics was selected.

36
3 . 5 S AM P L E S I Z E

The study sample size therefore consisted of twenty one PHC

clinics and the four CHC’s. CHC’s were included in this study,

since they provide additional services compared to PHC clinics,

and it was essential to identify challenges in the management of

drug supply, according to the objectives of the study in all

areas of primary health care.

More specifically the sample size consisted of:

 21 facility managers (FM) in the PHC’s (N1=21)

 4 FM in the CHC’s (N2=4)

 21 store managers in the PHC’s(N3=21)

 4 store managers in the CHC’s (N4=4)

 5 transport officers (N5=5)

The FM and the store manager questionnaire s are combined

with separate sections applicable to each category. In the

absence of a store manager, the FM will be requested to

complete the entire questionnaire.

3.6 PILOT STUDY

The pilot study was conducted in the remaining two sub-districts

namely, Lesedi and Midvaal and included two PHC clinics from

each sub-district prior to data collection for the actual study.

37
The aim of the pilot study was to identify any problems that the

respondents might have with the questions, so that

modifications could be made to the questionnaires accordingly

(Stead & Struwig, 2001). The data collected from the p ilot

study was excluded from this study.

3 . 7 D AT A C O L L E C T I O N

Data collection commenced as soon as approval was received

from the University of Limpopo, Medunsa Research Ethics

Committee (Appendix 9). Data was collected by the researcher

with the assistance of two pharmacists, who are currently

involved in monitoring and evaluation of DSM at PHC clinics

and CHC clinics. In order to ensure standardization in the

administration of the questionnaire the pilot study was

conducted by the principal researcher and the two research

assistants. Thus any problems/challenges arising during the

administration of the questionnaires were addressed prior to

data collection of the actual study.

Two data collectors (research assistants) were allocated to

eight clinics each, whilst one data collector was allocated to the

remaining nine clinics, and in addition also administered the

transport officer questionnaires. Data collection continued for a

38
period of two months commencing on 20 June 2011 until 20

August 2011.

To address the listed objectives, data was collected through

the following means:

 A questionnaire administered to the transport officers

(Appendix 3),

 A questionnaire administered to FM and/or store managers

(Appendix 4),

 A researcher check list (Appendix 5),

 A document review process of bin cards and order files of

the facilities,

 A drug tracer list to establish availability of tracer items at

the facilities (Appendix 6).

Data collection for FM and store managers was conducted at the

respective facilities, whilst data collection for transport officers

was conducted at the district office.

The questionnaire was administered to transport officers, to

determine the distribution process in terms of availability and

accessibility of drugs at PHC level (Appendix 3). The

39
questionnaire which was administered to FM and store

managers addressed the following objectives (Appendix 4):

 Availability of stock control processes,

 Availability of appropriate infrastructure to store the drugs

according to GPP requirements at PHC level,

 Availability of trained personnel to manage drug supply.

All facilities and transport officers completed the questionnaire.

The researcher checklist was used to verify aspects of the

facility and store manager’s responses to the questions. This

verification process was conducted at the respective PHC

clinics and CHC clinics (Appendix 5).

A document review process was conducted at the respective

PHC clinics and CHC clinics which identified whether optimal

stock control systems are in place which would ensure

affordable and acceptable drugs at PHC level ( presence of bin

cards and order files at all facilities) . This process was

conducted by reviewing order files and stock cards of all tracer

medicines (Appendix 6) at all the clinics, over the period of two

months. The stock cards and order files were evaluated by the

researcher, after the FM had completed the questionnaires. The

researcher had a checklist to assist in reviewing the stock

40
cards and order files. The checklist also assisted in verifying

the authenticity of the data collected.

The purpose of this document review process was therefore to

establish:

1. If bin cards were regularly updated,

2. If stock was counted and updated on the bin card during

receipt and issuing of medication,

3. If ROL’s were adhered to on order files.

Three months of retrospective data from stock cards and order

files, was reviewed against a researcher check list (Appendix 5)

and compared to prospective data obtained from the

questionnaires as indicated below.

A questionnaire which had been designed by Management

Sciences for Health to assess PHC facilities was adapted for

the purposes of this study. Currently, a monitoring tool from the

Sedibeng District Drug Supervisory manual is used to monitor

DSM in the district. The tool contains different aspects of DSM.

The tool is available in the clinic supervisor’s manual and is

used during monitoring and evaluation visits by the assistant

41
director of the clinic. Questions from this current monitoring

tool were also used where applicable.

The questionnaire was completed in the presence of the

researcher and was administered as an interview. The lengthy

questionnaire was subdivided into three sections. Section A

comprised of questions related to human resource management

in the facility. This section was administered to the most

appropriate person i.e. the FM. Section B and Section C was

administered on two separate occasions to the store manager,

since these comprised of questions relating to storage of

medication and medicine management processes. In the smaller

PHC clinics where there was no store manager, the person who

was responsible for DSM, was requested to complete the

questionnaire. Drug availability was checked against a list of

tracer drugs (Appendix 6) for the purpose s of this study.

3.8 DAT A ENTRY

All data collected during the study was captured in a Microsoft

Excel spreadsheet. Data capturing was verified and validity

checks were performed.

42
3.9 STATISTICAL AN ALYSIS

Statistical analysis was of a descriptive nature with the

responses to categorical variables summari sed by frequency

counts and percentages. Problems affecting DSM, as

determined in the study were prioritized on the basis of

incidence. All statistical procedures were performed on

Statistical Analysis Software, Release 9.2, running under

Microsoft W indows for a personal computer.

3.10 ETHICAL CONSIDERATIONS

Ethical approval was obtained from the University of Limpopo ,

Medunsa Research Ethics Committee. Permission was also

obtained from the Director of the Sedibeng d istrict to conduct

the study at all PHC and CHC clinics. Participants signed an

informed consent form after the researcher had explained the

aim of the project to the participant. Questionnaires were

anonymous and therefore the identit ies of participants were not

revealed. Data was collected and placed into a sealed box

which was stored at the district office. Each questionnaire was

allocated a unique reference number, which was linked to the

facility name. This was for the purposes of the researcher only,

and was not indicated in the research report. The same process

43
applied to the transport officer. Anonymity and confidentiality

was thus consistently maintained.

3.11 RELI ABILITY AND V ALIDITY OF THE STUDY

Reliability was achieved by standardising the measurement

procedure, so that the procedures were always the same (Stead

& Struwig, 2001). Validity was tested during the pilot study

conducted prior to the actual research data collection process.

This was performed to ensure that all questions asked were

understood correctly, and that the researcher and research

assistants were satisfied with responses to questi ons.

Therefore, the pilot study improved the internal validity of the

questionnaire. All captured data was cross-checked and proof-

read by the researcher to ensure accuracy.

3 . 1 2 B I AS

The researcher and research assistants visited the different

PHC and CHC clinics, and data collection was done during this

time. The researcher and assistants observe d the completion of

the questionnaire so that participants could not refer to

resources. The questionnaire was administered in the official

workplace language i.e. English in order to eliminate any form

of bias.

44
3.13 LIMITATIONS OF THE STUDY

The impact on DSM by the recent placement of PA’s could not

be measured due to the short period of time spent at PHC

clinics. In addition, a baseline study has not been conducted

prior to the placement of the PA’s at PHC level to determine the

impact of the PA’s at PHC level on DSM.

The study also has its limitations in terms of feedback from the

district pharmacy. The district pharmacy was not included in

this study and the impact of drug out of s tocks in the district

pharmacy was not established in this study. Hence it cannot be

ascertained as to whether the ordering roster issued by the

district pharmacy to the PHC clinics was adhered to by the

clinics.

This chapter summarises the method, study site, sample size,

data collection and method of data analysis. The next chapter

summarises the results acquired through questionnaires

administered

45
 CHAPTER 4

RESULTS AND DISCUSSION

This chapter summarises the results acquired based on the

questionnaires administered and discusses the most distinctive

of these results.

SECTION A

4.1 HUMAN RESOURCES

4.1.1 Staff member responsible for drug supply management

Figure 4.1: Percentage of clinics that rely on specific

individuals for DSM (N=25).

46
  There was specific individual/s, in all 25 clinics that were

responsible for DSM.

 DSM was performed by the FM or nurse in only one of the

clinics.

 PA’s were responsible for these duties (DSM) in 80% of the

clinics interviewed.

 Furthermore, of the 80% of clinics (20), only four of them

had full-time PA’s employed.

 Fourteen of the 25 clinics were visited by the assistants on

a weekly/bi-weekly basis. These assistants rotated from

one clinic to the other on different days due the shortage

of assistants.

As established from the results, the fact that fourteen clinics

had part time PA’s, which resulted in drugs not being checked

and unpacked immediately when they were received. This could

result in patients not receiving medication on time and

contribute to situations where clinics are out of stock.

However, from the results of this study it became clear that

there is a need for full-time PA’s at PHC level, as was

confirmed with the study performed by (Gray, Gengiah &

Naidoo, 2005). The acute shortage of professional human

47
resources necessitates the need to look at mid-level workers

such as PA’s to deal with the shortage of personnel at PHC

level.

PA’s have been an ever-growing part of the health care delivery

in both the public and the private sectors since the late 1980’s

(Gray et al., 2005). According to the South African Pharmacist’s

Assistants Journal, volume 2 of 2002, training of PA’s is helping

to develop skills in pharmaceutical services ( Carol, 2002).

Furthermore, if key health care professionals are in short

supply e.g. nurses and pharmacists and certain routine,

repetitive tasks normally undertaken by such professionals can

be safely and efficiently delegated to suitably-trained alternate

cadres of mid-level workers (Gray et al., 2005).

If these tasks become more routine requiring less cognitive

skills or professional judgment, then such tasks are perhaps

suited for delegation to an appropriate sub -professional group,

namely PA’s. Weber and colleagues found that pharmacist

technician teams in patient care units improved the service and

the satisfaction of the nursing personnel (Weber, Skle da,

Sirianni, Frank, Yourich & Martinelli, 2004). In South Africa

currently no training is offered as a pharmacy technician.

48
However, training of pharmacy technicians is planned for and

will be implemented by 2013 according to the SAPC.

4.1.2 Nursing staff trained in dispensing

Table 4.1: Differences in the number of trained, untrained and

in-training nurses in dispensing (N=208)

Trained In-training Un-trained

No. of % of No. of % of No. of % of
nurses facilities nurses facilities nurses facilities
0 4 (1/25) 0 64 (16/25) 0 4 (1/25)
1 8 (2/25) 1 24 (6/25) 1 28 (7/25)
2 36 (9/25) 2 8 (6/25) 2 28 (7/25)
3 8 (2/25) 3 4 (1/25) 3 20 (5/25)
4 24 (6/25) 5 4 (1/25)
6 4 (1/25) 8 4 (1/25)
7 4 (1/25) 9 4 (1/25)
9 4 (1/25) 12 4 (1/25)
10 4 (1/25) 23 4 (1/25)
12 4 (1/25)
TOTAL
NO. OF 94 21 93
NURSES:

From the results obtained, only one clinic had no trained nurses

in dispensing.

The set of norms and standards for PHC clinics recommends

that there should be at least one dispensing trained staff

49
member per clinic (Blaauw, Chabikuli, Gilson & Schneider,

2005).

4.1.3 Availability of a dispensing license according to the

researcher checklist (appendix 5)

According to the researcher checklist only 34 nurses out of a

total of 208 had either a dispensing l icence or a section 56A

permit. If a registered nurse does not have a dispensing

licence, a registered nurse must obtain authorisation from the

medical practitioner in charge of a specific on-site clinic in

order to be able to prescribe Schedule 1 to 6 medicines,

dispense and manage stock, in accordance with the regulations

of the South African Society of Occupational Nursin g Health

Practitioners. The medical practitioner must complete a

specified authorisation form in respect of the specific treatment

protocols for which a particular nurse is permitted to prescribe

medicines. The registered nurse may only prescribe the speci fic

medicines if the medical practitioner is not personally available

at the on-site clinic to diagnose the patient and prescribe and

dispense the required medicine him or herself (Kruger, 2009).

The lack of availability of section 38A or a section 56A

indicated that nurses were assessing patients and dispensing

50
medication but were not trained in PHC and had not c ompleted

the dispensing course. Irrational prescribing is one of the

factors contributing to drug shortages. The H ST attributes

irrational prescribing to poorly-trained staff. They argue that

quite often poorly-trained prescribers prescribe irrationally,

resulting in drug shortages (Matse, 2005 b). According to this

study, out of a total of 208 nurses, 93 nurses were not trained

in dispensing. Even though the remaining 115 nurses were

trained in dispensing, only 34 of these had physical evidence of

the dispensing license/permit.

4.1.4 Learner Basic and Post Basic PA’s trained in

dispensing

Table 4.2: Differences in the number of trained, untrained and

in-training PA’s in dispensing (N=21)

Trained In-training Un-trained

No. % of No. % of No. % of
of facilities of facilities of facilities
PA’s PA’s PA’s
100%
0 52% (13/25) 0 64% (16/25) 0
(25/25)
1 48% (12/25) 1 36% (9/25)
TOTAL
NO. OF
12 9 0
PA’s:
N=21

51
 Fifty percent of the clinics had learner basic PA’s in

employment (learner-basic). According to the scope of

practice, these assistants are not allowed to dispense

unless under the direct supervision of a pharmacist .

However, they are allowed to manage stock in a store in

terms of ordering and receiving stock, balancing bin cards,

establishing ROL’s and monitoring usage.

 Forty eight percent of the clinics had one qualified post

basic PA. (Qualified post basic PA’s are allowed to

dispense medication under indirect supervision of a

pharmacist in conjunction with specified protocols at PHC

clinics).

52
4.1.5 Training in Drug Supply Management

25

20
Number of clinics

15

10

0
0 1 2
Number of nurses trained in DSM

Figure 4.2: Number of clinics with nurses trained in DSM

(N=25).

 In 88% of the interviewed clinics there were no nurses who

had received training in DSM in the last twelve months.

 From the results obtained in this study, there is definitely

a need for ongoing training in DSM. According to the PHC

supervisory tool, nurses have to be trained in DSM in order

to effectively manage drug supply.

Each health facility has the responsibility of identifying the

individuals with the required knowledge, skills and experience

in DSM, who are permitted by laws, regulations or registration

53
to prescribe or order medications. The health facility also

identifies any additional individuals, who are permitted to

prescribe or order medications in emergency situations. Policies

and procedures define the documentation required for the

ordering of medications or prescribed items and for verbal

medication orders (W hittaker, 2011).

SECTION B

4.2 INFRASTRUCTURE AND SECURITY

Infrastructure and security forms part of section b and include

the storage of medicine, the condition of a store room,

availability of a secure delivery area and access control

measures.

4.2.1 Storage area of medicines

The following results were found in terms of the storage of

medicines:

 In all 25 clinics medicine is stored in the nurse’s

consulting room. (Medicine is allowed to be stored in a

consulting room provided it complies with GPP practice

requirements).

 In 21 of the clinics medicine was also stored in the

medicine store. (Medicine is allowed to be stored in a

54
 medicine store provided it complies with GPP practice

requirements).

 Nineteen clinics claimed that the storage area is not large

enough to store all the stock for a mon th’s supply.

 Thirteen out of the 25 clinics admitted that there were

drugs that were being stored in direct contact with the

floor as indicated in figure 4.3 below.

Figure 4.3: Stock on the floor (Clinic A).

According to the researcher checklist:

 Twenty of the clinics stored medicines in the medicine

store,

 In addition to storing medicine in the medicine store, 23

facilities also stored medicines in the nurses consulting

rooms.

55
  In 16 clinics, it was admitted that medicines were not the

only items stored in the areas described above. Other

items that were stored in these areas included stationary,

dry stores, pap, milk and even toilet paper.

The study found that there are discrepancies between the

researchers’ checklist and the FM questionnaire results in terms

of medication stored in nurses consulting rooms and other items

stored in the medicine store. Such a situation results in

unauthorised access to the medicine store which could result in

losses encountered. “Other items” in t he medicine store also

contributed to the lack of space.

Figure 4.4: Milk powder stored in the medicine room leading to

unauthorised access to the area and contributing to a shortage

of space (Clinic B).

56
A previous study stated that store rooms are needed in every

facility to store drugs and medical supplies safely and that the

size of the store room should be determined by the consumption

data of the clinic (Dukes et al., 1997). However, in Sedibeng

some clinics consist of two rooms and drugs are stored on the

floor wherever space is available as established from the

results of the study.

4.2.2 Condition of store room

The following results were obtained in terms of the condition of

the store rooms:

 Twenty three of the clinics (92%) had no cracks and holes

in the walls of the medicine storage are as,

 Twenty four of the clinics (96%) had a ceiling that was in a

good condition in the medicine storage area.

57
Figure 4.5: Cracks in medicine store wall at a clinic

(Clinic C).

According to the study conducted by Dukes et al., (1997), well-

located, well-built, well-organized and secure storage facilities

are an essential component of a DSM system. An appropriate

building provides the correct environment for the storage of

drugs and assists the efficient flow of supplies.

58
Figure 4.6: Broken ceiling panel (Clinic D).

A broken ceiling panel can result in pest infestation and rain

water entering the store, resulting in damage to drugs.

4.2.3 Secure delivery area

The following results were obtained in terms of the availability

of a secure delivery area:

Figure 4.7: Availability of secure delivery area .

59
  Only one clinic (4%) claimed that there was a secure

delivery area for their medication.

 The lack of a secure delivery area for 24 clinics poses

numerous challenges in terms of the following:

 Unauthorised access to medication,

 Loss of medication through theft,

 Damage of stock due to adverse weather

conditions.

4.2.4 Protection of medicine from direct sunlight

The following results were obtained in terms of methods of

protection of medication from exposure to sunlight:

Table 4.3: Percentage of clinics employing a specific method of

protection from sunlight (N=25)

Method of protection from Percentage of clinics employing

sunlight the method
Blinds 32%
Paint 4%
None 20%
No store room 4%
No sun inside store room 4%
No windows 36%

60
Figure 4.8: Blinds protect medication from direct sunlight

(Clinic B).

Figure 4.9: No protection from sunlight at other clinics

(Clinic E).

Figure 4.10: No protection from sunlight, no electricity in store

room (Clinic C).

61
The lack of electricity in the store room can result in:

 Incorrect medication being issued ,

 Inability to fill in stock cards,

 No temperature control,

 The lack of protection against sunlight contributes to

deterioration of medication and does not comply with

GPP requirements for storage of medication.

4.2.5 Pest infestation

The following results were obtained in terms of pest infestation

at the various clinics:

Twenty two of the clinics admitted that the medicine storage

area was free from any signs of pest infestation.

Figure 4.11: Dead insects in light cover (Clinic D).

The above indicates the presence of insects in the medicine

store which does not comply with GPP requirements of good

62
housekeeping and a pest-free environment. This can result in

contamination and damage of medication (SAPC, 2010).

4.2.6 Access control

The following results were obtained in terms of access control:

 Twenty three of the clinics claimed to have controlled

access measures in place for the entry of unauthorised

persons into the medicine store.

 In 50% of the clinics the key to the medicine

store/pharmacy was kept in the possession of the sister in

charge.

 In nine clinics, the key to the medicine store was in the

possession of the PA. However, in the clinics where PA’s

rotated between the clinics, the key would then be left in

the key cupboard during the interim period, which could

result in uncontrolled access.

4.2.7 Security of the medicine room

Nine of the clinics had a security door and eight clinics had

burglar bars as an available security measure.

63
Figure 4.12: Lack of security-medicines easily accessible

(Clinic E).

According to the GPP, medication must be stored in a locked

area, ensuring no unauthorised access to the medication

(SAPC, 2010). Institutions within the Department of Health are

required to comply to this requirement in medicine stores and

consulting rooms where medication is allowed to be stored.

SECTION C

4.3 STORAGE AND CONTROL PROCESSES

4.3.1 Delivery and receipt of medication

Taking into account that one clinic did not fill in the data, it was

established that twenty four of the clinics received stock by two

specific procedures:

64
 1. The number of boxes is checked and the driver’s

note is then signed.

2. Stock received is checked against the invoice.

Table 4.4: Relevant person/s responsible for receiving stock in

the clinics (N=39)

Person responsible for receiving

No. of clinics
stock

PA (basic and post basic) 21

Pharmacist 0

Nurse 8

Store manager 0

Security 0

Facility Manager 10

Note: More than one person may be responsible for receiving

the drugs at these facilities. However, when a PA is not

available, a nurse would receive the drugs.

 In 56% of clinics, stock is checked within the same day of

receipt.

 In 40% of the clinics, stock is checked within 24 hours.

 In the remaining four percent, receipt of stock is checked

within a week of delivery.

65
One of the key elements in DSM is to ensure th at medication

is checked within twenty four hours of receipt. The risk of

misappropriation of drugs increases if drugs are not checked

immediately. According to Dukes et al., (1997), dedicated

personnel need to be available to check deliveries

immediately.

According to this study, stock was checked within twenty four

hours of receipt in 40% of the clinics. Although the issue of

theft of medication was not investigated in this study, not

checking medication upon receipt creates an environment

which could allow for the misappropriation of drugs.

60

50

40
Percentage (%)

30

20

10

0
Same day Within 24 hours Within a week
When is stock checked after receipt

Figure4.13: Checking of stock after receipt thereof according

to the questionnaire (N=25).

66
Furthermore, not checking stock as soon as possible after

delivery can result in discrepancies such as a shortage or an

excess in delivery being not being identified. This in turn

results in paying for medication not received or not ordered .

Ultimately this will impact on either out of stocks or excess

stock which can lead to patients not receiving medication or

expired stock.

4.3.2 Checking of stock according to transport officers in

the presence of security officers

Procedurally, security officers are required to be at all clinics

and are required to check all deliveries at clinics. After a

security check, a staff member is requested to verify the

number of boxes received by security personnel.

Table 4.5: Presence of security officers during the receipt of

medication according to the transport officers (N=4)

Presence of security personnel No. of transport

during the receipt of medication officers

Always 1

Never 1

Sometimes 2

67
The results obtained from the four transport officers as

indicated in Table 4.6 were contrary to results obtained from

the questionnaire administered to the FM in terms of receipt of

medication (Table 4.4). (Some of these questions were not

asked to FM’s).

Table 4.6: Persons responsible for receiving stock according to

the transport officers (N=10)

Person/s responsible for receiving No. of transport

stock according to transport officers officers

Store manager 2

Facility manager 2

Security 3

PA 1

Nurse 1

Depends who is available 1

 Note that all four transport officers stated that there was

no dedicated person to receive the order when delivered to

the clinic.

 It was also indicated that there may be more than one

person responsible for receiving the order at the clinic.

68
 Three transport officers reported that the number of boxes

are only checked ‘sometimes’ when the delivery is received

at the clinic.

 In cases where the boxes are not checked immediately

various procedures are followed such as ‘the boxes are left

outside with security and if a PA is available, the boxes

are counted’, or ‘sometimes the number of boxes is

counted, at other times boxes are left outside the door at

the clinic without being checked’.

 There is always an accompanying delivery note with each

order. In the case where the order does not correspond to

the delivery note, only one transport officer admitted that

he contacts the district pharmacy only if the clinic refuses

to accept the order.

 Three transport officers stated that the delivery note is not

signed by the person receiving the order. One transport

officer stated that it was sometimes signed.

 Furthermore, two of the transport officers said that a

signed copy of the delivery note is only ‘sometimes’

returned to the pharmacy.

 The remaining two said that a signed copy of the delivery

note is never returned to the pharmacy. (It is the joint

responsibility of the clinic, the transport department and

69
 the district pharmacy to ensure that t he signed delivery

note is returned to the district pharmacy. However, this

rarely happens due to all sectors not following procedure) .

The lack of dedicated personnel is also a contributing

factor since it is difficult to pinpoint the culprit.

 Three transport officers admitted that there have been

discrepancies in terms of the actual number of boxes of

medication delivered.

According to Dukes et al., (1997), when medication is delivered,

the responsible person receiving stock must carry out a

complete inspection of every delivery immediately upon

delivery. The stock received must be kept separate from other

stock until inspection has been completed. The respo nsible

person should check for damaged and missing items and

reconcile the drugs received with the order placed. Items

requiring special handling such as cold chain items and

schedule 5 or 6 items need to be stored immediately. Security

breaches include theft, bribery and fraud. These can occur at

all levels of the drug purchasing and distribution system.

70
There are three common forms of theft and leakage:

Slow, chronic, sustained, small-scale leakage may go unnoticed

for a long time. Staff members with access to drug storage

areas are usually responsible for such thefts. Large scale

robbery may involve people both inside and outside the drug

supply system. Diversion of a delivery before it reaches its

destination may involve people in responsible po sitions with

access to information on movement of drugs. These can have a

substantial and sometimes disastrous economic and health

impacts (Dukes et al., 1997). The lack of implementation of a

proper system to receive medication at the clinics in Sedibeng

makes it very easy for theft of stock to occur.

Some factors that promote theft are:

 Shortage of essential drugs or a high demand for drugs in

the private sector,

 Poor physical security in stores,

 Inadequate and incomplete inventory records,

 Unlimited access to stores by unauthorised personnel,

 Staff whose salaries are significantly lower than necessary

for self support (Dukes et al., 1997).

71
The discrepancies between the responses of PHC personnel and

transport officers indicated that there are serious issues which

need to be further investigated in order to establish the actual

processes followed during the delivery and receipt of

medication. This indicates that a problem exists in terms of

dedicated personnel to manage the receipt of stock.

Discrepancies in the number of boxes delivered also indicate a

lack of security and a lack of dedicated personnel which can

contribute to losses by means of theft. Due to the discrepancies

in the reports, findings of other studies could be app licable in

this study in terms of theft and diversion of stock during

delivery and incomplete inventory reports.

4.3.3 Packing of stock in the medicine store and the

consulting room

 Two facilities did not pack medicines according to the first-

in/first-out basis (FIFO) principle in the medicine store.

 Eight facilities did not pack medicines according to the

first expired-first out (FEFO) principle in the consulting

room.

 Seventeen of the clinics had no damaged containers or

packages on the shelves of the medicine store or

consulting room.

72
In a previous study conducted by Dukes et al., (1997), it

showed that in order to avoid accumulation of expired and

obsolete stock, a stock rotation system needs to be in place to

determine which items need to be used first on either a FIFO or

a FEFO basis. The findings in this study can be linked to Dukes

et al., (1997), in terms of the lack of FEFO or FIFO principles

contributing to expired and obsolete stock.

The cost of expired stock in one clinic in this study was as high

as R126 203.00. This figure equates to the drug expenditure of

an average PHC clinic per month. The high value of expired

stock is an indicator of an improper stock rotation system.

Deterioration and spoilage costs for drugs are more likely to

occur with poor storekeeping practices, but there is some risk

in all storage areas of medicine. In general, these costs are

incremental- the higher the stock levels, the higher the costs of

spoilage. Inadequate storage areas withi n the NDOH results in

an increase risk of damaged and expired stock and this has a

negative impact on an already strained budget (Dukes et al.,

1997).

73
4.3.4 Ventilation and Temperature control within facilities

Table 4.7: Ventilation and temperature control systems (N=25)

Form of ventilation No. of clinics

Fan & windows 1

Airbricks 1

Air-conditioner (functional) 11

Air-conditioner (non-functional) 6

None 4

Missing data 2

Figure 4.14: Typical type of air-conditioner present in the 17

clinics with air-conditioners (Clinic F).

According to the FM’s response to the questionnaire 40% of

facilities had an available temperature chart which was

recorded twice daily. However, according to the researcher’s

74
checklist, the following was noted in terms of temperature

control:

 Eleven clinics had a temperature chart available in the

medicine store and only ten clinics were updated regularly.

 Two clinics had both an available and regularly updated

temperature chart in the consulting room.

75
 Updated + available
Updated + available

Available
Available

Figure 4.15: Availability of updated temperature charts in th e

medicine store and consulting rooms according to the

researcher checklist (N=25).

From the above results, 15 clinics did not monitor temperature

in the medicine store which could negatively impact on the

potency of medication.

It is essential to follow the product manufacturer’s storage

instructions as closely as possible. If this is not possible, the

product must be kept in the most suitable conditions available

and used up as quickly as possible. Extreme temperature

76
changes can damage some items thus affecting the potency and

efficacy of the items (Dukes et al., 1997).

4.3.5 Cold chain management

Table 4.8: Cold chain management (N=25)

% of
% of
clinics
clinics
according
according
to
to facility
researcher
manager
checklist
Only medicines stored in all 96% 96%

medication fridges

Available sufficient space in the 68% *

refrigerator to store medication

Presence of a thermometer in the 96% *

fridge

Temperature of refrigerator maintained 92% 96%

between 2-8°C

Temperature is recorded twice daily 92% 64%

Fridges defrosted & cleaned twice a 52% 32%

month or when ice is more than 5mm

There is a backup generator in case of 20% *

a power failure

Cold chain maintained when receiving 96% *

stock from the district pharmacy

77
*Note: Data is not available as all the questions posed to the

FM’s were not present on the researcher checklist.

Figure 4.16: Ice thicker than 5mm in fridge ( Clinic E).

Medications depend on suitable storage for their potency. In

particular, vaccines which are exposed to high ambient

temperatures and/or freezing will quickly lose their potenc y

(Dukes et al., 1997).

According to transport officers:

 Only two transport officers maintained the cold chain when

delivering medication. The other two admitted that it is

only ‘sometimes’ maintained and not reported if it is not

maintained.

78
  In the Sedibeng district, cold chain items usually consist of

one cooler box and the transport officer takes it into the

facility. Cold chain items are delivered weekly due to the

lack of generators at the clinics.

From the results of the study, it is clear that cold chain is not

always maintained by transport officers. Transport officers need

to be educated on the importance of maintaining the cold chain

as outlined below.

Cold chain is the system of transporting and storing vaccines

within the safe temperature range of 2 -8°C. For vaccines to be

effective, the cold chain must be maintained from the place of

manufacture to the point of administration.

Each time that vaccines are exposed to the wrong temperature,

their potency is reduced. To know if vaccines are potent at the

time of administration, it is important that they be monitored for

exposure to heat and cold as they pass through the cold chain.

While domestic refrigerators are not designed to meet the

requirements of vaccine storage, safe storage is possible if

healthcare facilities follow simple guidelines. Guidelines may be

obtained from the health authorities or from the manufacturers

79
and distributors of vaccines. Foodstuff must not be stored in the

medication refrigerator (Dukes et al., 1997).

4.4 MEDICINE MAN AGEMENT AND PROCESSES

4.4.1 Inventory system used

All the facilities use a manual/paper based inventory

management and stock control system. A standardised

computerised system linked to the district pharmacy can assist

in the monitoring and evaluation of stock.

4.4.2 Availability of bin cards

 The bin cards for tracer items are available in the

medicine rooms of 19 facilities.

 In contrast only one consulting room had available bin

cards for tracer items.

 From these medicine rooms and consulting rooms only

thirteen of them had regularly updated bin cards.

According to Dukes et al., (1997), the use of stock cards as a

tool for stock control should be enforced and should be

monitored by supervisors. Establishing and maintaining

effective inventory records and procedures are the basis for

coordinating the flow of drugs through the distribution system

80
and the primary protection aga inst theft and corruption. The

inventory control system is used for requisitioning and issuing

drugs, for financial accounting, and for preparing the

consumption and stock balance reports necessary for

procurement. Record keeping must be sufficiently detai led to

provide an “audit trail” that accurately traces the flow of drugs

and funds though the system. An appropriate inventory

management system should be adapted to suit the capacity and

needs of personnel at all levels in the health program. Inventory

records must be monitored regularly by supervisors to ensure

accuracy and to avoid or detect losses (Dukes et al., 1997).

In Sedibeng, due to a lack of dedicated personnel for DSM, it is

difficult to ensure consistent record keeping. This leads to a

lack of updated documentation which makes it difficult at clinic

level to have an audit trail. Even if losses occur through theft,

these would be difficult to establish unless such incidents are

physically witnessed.

4.4.3 Method of calculating ordering quantities

 In 21 clinics, the ROL was reflected on the stock card.

However, the ROL’s levels are not reviewed or utilised

when ordering stock.

 One facility calculated the average monthly consumption.

81
  The data from one clinic was missing.

The lack of review and usage of ROL’s by the clinics is a major

contributing factor to the shortage of drugs. This can also lead

to over ordering, resulting in obsolete and expired stock.

4.4.4 Re-order levels

Seventeen clinics had ROL’s for the tracer items in the

medicine store and one clinic for tracer items in the consulting

rooms.

4.4.5 Calculation of re-order levels

 Twenty percent of the clinics admitted that the ROL has

not been calculated for all tra cer items in the store.

 Only 35% of the remaining 80% that had ROL’s review

these regularly.

 In six of these clinics the review is conducted every three

months.

 In one clinic ROL’s are reviewed monthly.

82
 a.
30

Re-order level available

No re-order level available
25
Data missing

20
No. of clinics

15

10

0
Medicine store Consulting room
Evidence of re-order levels of tracer items
b.

3 clinics
7 clinics

15 clinics

Figure 4.17: Evidence of ROL’s (a) and quarterly review thereof

(b) (N=25).

83
In a study conducted on DSM in the Mopani district, none of the

workers understood the method they claimed to use to

determine quantities to be ordered. Whether it was Maximum

and Minimum Stock Order Levels, Consumption -Based ROL’s or

the Average Monthly Consumption, the workers had no clue how

these formulas were used. As a result the study concluded that

staff relied on their working experience to determine the

quantities to be ordered. Twenty nine percent of the facilities

indicated that they had no formal method of quantifying their

orders. The stock outs and overstocking found in Mopani could

mainly be attributed to the lack of knowledge with regard to

quantification methods (Matse, 2005b). In the Sedibeng district,

the lack of review of ROL’s can be linked to the find ings of the

study in the Mopani district where no method was used to

quantify medication orders.

Matse argued that a third of procurement and distribution

processes are compromised by lack of adequately trained staff.

He argued that, “the professionals who are expected to ensure

proper purchase, utilisation and appropriate use of those drugs

often lack basic knowledge on the management of drug

supplies” (Matse, 2005b).

84
4.4.6 Quantity and period of stock out at clinics

 Eight facilities had at least one tracer item out of stock .

 Only one facility had no tracer items out of stock.

 According to the researcher checklist, the number of non -

tracer items out of stock varied significantly at each clinic,

with only three clinics having no out of stocks for non -

tracer items and one clinic having as much as eleven non -

tracer items out of stock. The discrepancies in the results

clearly indicate that some clinics had a specific method

of ordering whilst other clinics ordered hap hazardly,

resulting in a high percentage of out of stocks.

 Although non tracer items are regarded as essential but

not vital, the reasons for out of stocks and the number of

non tracer items out of stock is important in this study.

According to Circular Minute 118 of 2009, the MEC for Heath in

Gauteng requested a 99.5% availability of drugs in Gauteng

(GDOH, 2009). In order to meet this target, both tracer and non

tracer items availability needs to be established. The

availability of non tracer items was established through the

researcher checklist.

85
According to the researcher checklist:

 The number of out of stock items varied considerably with

four facilities having one item out of stock according to the

tracer list, compared to as much as 16 items in one clinic.

Figure 4.18: Period of tracer items out of stock at clinics

(N=25).

86
Figure 4.19: Medication out of stock (Clinic B).

4.4.7 Responsibility for ordering of medication

 PA’s are responsible for ordering of medication for twenty

of the facilities ,

 In seven clinics of the above twenty clinics, the sister in

charge is also responsible for ordering of medication in the

absence of a PA.

 However in four clinics a nurse is in charge of this

responsibility.

 In one clinic the FM is in charge of ordering medication.

4.4.8 Expired medication and tracking of expiry dates

 Sixteen clinics had drugs which expired in the last twelve

months.

87
  The estimated monetary value of the items expired varied

from R30.87 to as much as R126 203.00.

 According to the researcher checklist the value of expired

stock for the last three months varied significantly from R0

(fourteen clinics) to as much as R23 000 (one clinic).

 Only four clinics had systems in place by which to track

expiry dates.

According to the NCS, an expiry tracking system will soon

become compulsory where each clinic will be required to have

an expiry register. Sedibeng has been experiencing a high

volume of expired stock at clinic level and an urgent compulsory

intervention strategy is necessary.

Figure 4.20: Damaged and expired medication (Clinic E).

88
 a.

b.

Figure 4.21: Medication packed according to FEFO (a) and

incidence of expired stock in the past 12 months (b) (N=25).

89
4.4.9 Stock take

25

a. Evidence of stock take present

No evidence of stock take
20 Clinics with missing data
No. of clinics

15

10

0
Medicine store Consulting room
Evidence of stock take

b.

Figure 4.22: Evidence (a) and frequency (b) of stock take

(N=25).

90
  In one clinic stock take was last conducted in 2010.

 In eleven of the clinics stock take was last conducted in

2011.

 Four clinics did not conduct any stock take at all.

 Data was missing from the remaining clinics.

According to the researcher checklist:

 Only fourteen clinics had evidence of stock take being

conducted in the medicine store.

 Two clinics had evidence of stock take being conducted in

the consulting room.

 The frequency of stock take in these facilities varied

substantially with seven facilities performing a monthly

stock take and only two facilities before every EDL order

(which varies from monthly to bimonthly depending on the

size of the clinic).

 Only 40% of the facilities counted stock prior to ordering

and only twenty eight percent recorded the re -order level

of each item on the order file.

In order to ensure efficient DSM, regular physical stock counts

is necessary so that drug movement can be monitored. Bin

91
cards should be used to control all the stock dispensed from

consultation rooms.

The study found that there were problems associate d with

management of stock card s. The physical stock on the shelves

was not equal to the balance quantities recorded on the stock

card because stock was not recorded at the time of movement .

It was thus difficult for clinics who did not maintain stock cards

to take stock. According to previous studies, Matse (2005b)

argued that if stock cards are correctly maintained they could

be used to calculate consumption and hence quantities to order.

The lack of stock take in the medicine store by 68% of the

facilities indicated that stock is not counted prior to ordering.

Hence the ordering process is conducted without determining

consumption of drugs from one order period to another. This

could contribute to out of stock and over stocking of certain

items. This could then result in patients not receiving

medication or medication expiring on the premises due to

incorrect re-orders levels.

92
Figure 4.23: Unopened stock stored on the floor ( Clinic B).

The boxes are still sealed implying that stock has not been

checked (Figure 4.23). There is no evidence of bin cards. The

district pharmacy often repacks stock in cardboard boxes and

seals these. Thus a sealed box may contain mixed items, which

in this case had not been opened and checked.

Stock records are the core records in t he inventory management

system. They are the primary source of information used in

various reordering systems.

Several factors contribute to inaccurate records:

 High volume, repetitious entries lead to occasional entry

errors just by the nature of the task. This is often found to

be the case during routine visits in Sedibeng. The

recording system is manual and if stock is not r ecorded as

93
 and when it is utilised (as was established in the study),

then errors can easily occur (Dukes et al., 1997).

 Duplicate entries for receipts or issues may be caused by

duplicate paperwork if more than one person is responsible

for DSM. This happens frequently at some clinics

especially in the absence of PA’s. Nurses take medication

from the store room and leave notes for the assistant to

enter into bin cards. This creates room for errors.

 Spoiled or damaged stock may be destroyed but not written

off the records.

 Theft produces inaccurate records, except where records

are deliberately altered to conceal theft.

 Physical stock counts may be rarely or never conducted or

the records may not be reconciled after stock counts as

has been established in the study.

 Sloppy warehouse conditions may make it difficult to

reconcile actual stock with recorded stock. In Sediben g,

small stores and stock in many different places in the

absence of a store room result in incorrect reconciliation

of stock.

 There is often little supervision of facilities medicine

stores, and limited effort by FM’s to reconcile

discrepancies (Dukes et al., 1997). FM’s are often

94
 overworked in the Sedibeng district with little or no time

for DSM.

4.4.10 Delivery of medication

a.

b.

Figure 4.24: Lead time between request and receipt of drugs

(a) and receipt of orders (b).

95
According to transport officers:

Table 4.9: Delivery of medication according to transport

officers (N=4)

% of transport officers

Orders have to be split due to 75%

insufficient space in the delivery

vehicle

Officers that admitted that only 75%

‘sometimes’ is the balance of the

order delivered on the same day

Availability of a delivery schedule 100%

 All four of the transport officers (i.e. 100%) stated that

there was no designated driver or vehicle to deliver

medication.

 Three of the vehicles used to transport medication are

normal cars and one vehicle is a closed van.

 All four of the transport officers admitted that they are not

always able to adhere to the delivery schedule. In the

Sedibeng district the turnaround tim e for an order is seven

days. Transport has been cited by many studies as one of

major problems affecting drug distribution. It is definitely a

contributing factor in this study. The results of the study

indicate the lack of a dedicated vehicle and a dedic ated

96
 driver to deliver medication is one of the contributing

factors to out of stock situations, since the turnaround time

for delivery of medication can be up to three weeks instead

of the required seven days.

4.4.11 Response to patients on medication stock outs

Figure 4.25: Process that is followed if the facility is out of

medication (N=25).

97
4.4.12 Feedback from district pharmacy

 Feedback regarding the status of orders is communicated

to all the clinics via the district pharmacy.

 No feedback from the transport department is received

regarding expected delivery.

 Feedback is given to the clinics regarding out of stocks in

the pharmacy but no feedback is given regarding the status

of to-follow orders.

The district pharmacy was not included in this study and hence

it cannot be ascertained as to whether the ordering roster

issued by the district pharmacy to the PHC clinics was adhered

to by the clinics.

4.4.13 Availability of documentation and ordering processes

 Twenty four of the clinics had available documentation

regarding the procurement and receipt of medication.

 Twenty of the 25 clinics had the documentation filed .

4.4.14 Reasons for out of stock situations

 Ninety six percent of the clinics cited the most

predominant reason for the experiencing of out of stocks is

because the district is out of stock. Further research needs

98
 to be conducted to establish factors influencing the

availability of stock at the dist rict pharmacy. However, this

study identified a lack of ROL’s, shortage of space in the

medicine store and a lack of DSM training which all affect

the availability of drugs at the clinic. In addition to this,

haphazard ordering patterns from clinics in Sed ibeng would

make it difficult for the district pharmacy to quantify the

needs of the clinics and this would affect the ROL’s of the

pharmacy.

 Although 22 clinics claimed that the medication stock out

is addressed within forty eight hours, eleven clinics have

indicated an average stock out period of tracer items of

eight days or more.

According to the researcher checklist more than 75% of the

clinics experience stock outs for the following reasons:

 Non adherence to ROL’s,

 Bin cards are not updated regularly (only when the PA is

present),

 Inaccurate consumption records,

 Insufficient space, resulting in stock being stored all over

the facility.

99
The findings of this study are consistent with challenges

identified in with other studies in terms of factors affecting DSM

(Matse, 2005b).

Figure 4.26: Insufficient space and lack of shelving ( Clinic B).

The above photo demonstrates black ordering boxes which

contain stock which has not been checked and packed due to

lack of storage space. It is difficult to identify what items are in

the box since the district pharmacy supplies mixed items in the

black boxes. A lack of space was cited as a reason f or not

unpacking the boxes. Hence clinics could report items as out of

stock or stock could expire in the boxes if these boxes are not

unpacked.

According to the study the following possible reasons have been

identified for not unpacking stock regularly a t clinics:

100
  The unavailability of a constant dedicated person to order

and receive medication,

 Mismanagement of stock due to lack of monitoring access

control in the absence of the PA,

 Possibility of theft due to stock not being checked and

packed immediately on receipt,

 Stock being left outside during delivery due to the absence

of a dedicated secure receiving area, resulting in spoilage

and theft.

Of the clinics interviewed only 50% of clinics claimed to have

been visited by the district pharmacist in the last month. Lack

of supervision by the district pharmacy results in a lack of

supervision of PA’s resulting in poor DSM. According to the

study, there is a lack of training of DSM at PHC’s. Increasing

support visits by pharmacists would assist in increasing onsite

training and monitoring and evaluation which could assist in

establishing ROL’s, monitoring expiry dates and adhering to

FEFO principles.

101
4.4.15 Standard operating procedures and reference material

Table 4.10: Percentage of clinics with the relevant available

SOP (N=25)

Standard Operating Procedure (SOP) Availability

in clinics
Control of access to dispensary or medicine 8%
room
Designation of the medicine room 8%
Issues to the district from the regional 20%
pharmacy
Organization of medicine room 28%
Security in the medicine room 28%
Receipt and storage of medicine 32%
Issues from medicine room to consulting 32%
rooms
Borrowing of medicine between institutions 20%
The use of stock cards (VA11) 28%
Stock taking in medicine and consulting 32%
rooms
Product types requiring special handling and 12%
storage
Cold chain management 32%
Checking and return of 20%
expired/obsolete/unusable and patient -
returned stock to the district pharmacy
Complaints of product quality and adverse 16%
drug reactions

102
  All clinics (i.e. 100%) had access to the EDL/STG for PHC

and 90% of these were 2008 editions.

 Only 22 clinics had access to a provincial formulary/code

list.

The next chapter contains a summary of the results and

conclusions.

103
 CHAPTER 5

SUMM ARY OF THE RESULTS AND CON CLUSIONS

This chapter summarises the findings of the study and

concludes the study.

SECTION A

5.1 HUMAN RESOURCES

The study found that there was no specific dedicated person to

manage drug supply at different PHC facilities in Sedibeng. At

fourteen facilities there were PA’s on a part time basis and

nobody was responsible for DSM in the absence of the PA. The

absence of a dedicated person to manage drug supply can be

linked to other studies where similar situations contributed to

out of stocks (Jha & Roy, 2005).

In one percent of the clinics a nurse or FM was responsible for

DSM. The task of managing drug stores often depends on the

already overburdened nurses and part -time PA’s. The nurses

were primarily responsible for providing health care to a large

population. It was difficult for them to spend the time required

to adequately store, maintain records and maintain the drug

104
items in the stores and to efficiently and effectively manage,

supply and dispense drugs. The production of professional

nurses has lagged behind in growth and the need for health

services in South Africa has not triggered appropriate policy

development and action in the area of nurse production. The

lack of clearly defined or accepted national staffing norms for

PHC constitutes a key gap in th e harmonisation between the

expansion of PHC services and the demand for nurses (Blaauw

et al., 2005).

From the results of the study, it became clear that there was a

need for full-time PA’s at PHC level, as was confirmed by a

study conducted by Matse (2005b).

5.2 TRAINING OF NURSES AND PHARM ACIST ASSISTANTS

 Training of nurses in DSM was not consistent amongst the

study sample.

 In 88% of the clinics no nurses were trained in DSM in the

last twelve months.

 Out of a total of 208 nurses only 34 nurses could produce

a dispensing licence or a section 56 A permit to dispense.

This implied that nurses were managing drugs and

dispensing medication without the appropriate qualification

105
 or authorisation. This was a direct contravention of both

the Nursing and Pharmacy Acts.

 In 50% of the clinics PA’s were learner basic and could

only perform certain functions in the absence of direct

supervision by a pharmacist.

 In 48% of the clinics the PA’s were post-basic and could

dispense under indirect supervision of a pharmacist.

 Both leaner basic and post basic assistants were not based

at one clinic permanently. Due to the shortage of trained

PA’s, they rotated between clinics. This resulted in a lack

of dedicated trained staff members to manage drug supply.

The first objective of the study was :

To establish the availability of trained personnel to manage drug

supply.

This objective was met by the results indicated above and it was

found that the Sedibeng district did not have sufficient dedicated

trained personnel to manage drug supply at each of the clinics .

106
SECTION B:

5.3 INFRASTRUCTURE AND SECURITY

5.3.1 Storage area of medication

 Nineteen clinics did not have large enough medicine stores

to store a month’s supply of medication. Inadequate

storage could result in clinics ordering according to

capacity instead of according to consumption, resulting in

medication out of stocks resulting that patients will not

receive medicines prescribed to them during out of stock

periods. This is undesirable and impacts negatively on

patient care.

 Other items such as toilet paper and milk powders were

also stored in the medicine store in sixteen of the clinics,

contributing to a further shortage of space for medicines ,

 Medication was stored on the floor due to insufficient

storage space,

 According to the GPP guidelines, the storage area in a

medicine store should be large enough to allow for the

orderly arrangement of stock and stock rotation. Medicines

may also not be stored on the floor (SAPC, 2010). Thus in

terms of GPP requirements for storage of medication, the

Sedibeng district failed to comply.

107
5.3.2 Condition of medicine store

In 23 clinics there were no cracks and holes in the wall s and

only one clinic had a broken ceiling panel. Sedibeng district

thus largely complied in terms of the condition s of a storeroom

according to GPP requirements (SAPC, 2010).

5.3.3 Availability of a secure delivery area

 Only one clinic had a secure delivery area.

 Lack of monitoring systems was identified during receipt

and inspection of medicines. In certain cases medicines

were left outside for long periods of time before being

checked. This could result in misappropriation and theft of

medication. According to the GPP, medicine s should only

be accessible to an authorised prescriber and should be

checked and stored in a locked area immediately upon

receipt. The Sedibeng district failed to comply with these

GPP requirements in terms of a secure delivery area

(SAPC, 2010).

5.3.4 Protection of medicine from direct sunlight

 The medicines in 20% of the clinics had no protection from

sunlight.

 One clinic had no electricity in the storeroom .

108
  According to the GPP, light conditions and temperature

must comply with the minimum standards for storage of

medicine (SAPC, 2010).

In this instance, the Sedibeng district did not fully comply to

GPP requirements (SAPC, 2010). This issue can be corrected by

addressing it with the relevant clinics.

5.3.5 Pest infestation

 Dead insects were discovered in the light fitting of one

clinic.

Good housekeeping practices according to GPP requirements

need to be emphasised with the specific clinic (SAPC, 2010).

5.3.6 Access control and security in the medicine store

According to the GPP, control of access to a medicine store

must be of such a nature that only the licensed dispenser(s)

has direct access to the medicine room (SAPC, 2010).

 According to the findings of this study, in nine of the

clinics the key was in possession of the PA. In the absence

109
 of the PA, the key was hung in the key cupboard, allowing

unauthorised access to the medicine store.

 Nine of the clinics had a security door and eight of the

clinics had burglar bars as a security measure .

 According to the GPP, all medicine stores need to have a

security gate and burglar bars (SAPC, 2010). The Sedibeng

district was thus partially compliant.

The second objective of this study was:

To explore the availability of infrastructure to store drugs at

PHC level according to GPP requirements .

The objective was met from the results outlined above.

However, from the results it was established that the district did

not comply fully with the required GPP requirements (SAPC,

2010).

SECTION C:

5.3.7 Delivery and receipt of medication

 It was established that different staff members received

medication ranging from the FM, nurse and PA.

110
  Stock was checked immediately or within 24 hours of

receipt, as expected.

5.3.8 Checking of stock according to transport officers in

the presence of security officers

Only one transport officer claimed that there was always a

security officer to check stock upon delivery . The other three

transport officers claimed that stock was checked only

sometimes. According to transport officers at other times

medication was left outside the clinic unchecked.

According to the GPP, medication should only be accessible to

an authorised prescriber (SAPC, 2010). The Sedibeng district

has a serious challenge due to a lack of secure delivery areas

at the clinics as well as dedicated staff members to receive

delivery of medication.

The Sedibeng district failed to comply with the necessary

requirements in terms of receipt and checking of stock.

5.3.9 Cold chain management

 Overall cold chain management was maintained within the

24 clinics.

111
  Some clinics claimed that transport did not maintain the

cold chain during delivery of medication.

 Nineteen clinics did not have back-up generators in

possible cases of power failure.

The Sedibeng district complied with cold chain management at

PHC level except for one clinic. This can be addressed with the

relevant clinic and staff members can be trained in terms of

cold chain management.

5.3.10 Arrangement of medication in the store room and the

consulting room

 According to the results, facilities did not pack medication

according to FEFO and FIFO resulting in expired stock

The third objective of the study was:

To study the distribution process in terms of availability and

accessibility of drugs at PHC level .

This objective was met by the results outlined above. The

district failed to comply in terms of adequate distribution

processes due to lack of dedicated personnel.

112
  The district complied in 20 clinics in cold chain

management but the transport department failed at times to

maintain cold chain.

5.4 MEDICINE MAN AGEMENT AND PROCESSES

5.4.1 Availability of bin cards

 The study found that facilities either did not have bin

(stock) cards or that bin cards were not updated regularly.

Hence, it made the task of managing drug supply difficult

since medicine usage could not be established.

Previous studies have found that one of the key elements of

effective distribution management of drugs at facility level is

the keeping of reliable records of drug consumption , e.g.,

according to a study conducted in the state of Bihar in India to

determine the reasons for drug shortages, it was found that

there was no bin card system. Stock registers were poorly

maintained. There was a lack of basic reordering skills at all

levels; for example not knowing how to calculate monthly stock

available and how to calculate orders on maximum and minimum

quantities (Jha & Roy, 2005).

113
According to a study conducted by Gray and Suleman, (2009), if

stock cards are correctly maintained they could be used to

calculate consumption and hence quantities to order. The lack

of updated bin cards contributed to a lack of adequate stock

control systems, which in turn contributed to drug out of stocks,

resulting in patients not receiving medication.

5.4.2 Method of calculation of drug ordering quantities

 The method of assessing drug requirements in the

Sedibeng district was not appropriate. The demand

estimations were not following criteria such as trends in

consumption patterns or ROL’s. Although some clinics had

ROL’s, these were not utilised when it came to ordering

drugs. It appeared that not many of the staff members

understood the method they claimed to use to determine

quantities to be ordered. Staff members were ignorant

about the different methods to determine ordering

quantities e.g. the Maximum and Minimum Stock Order

Levels, Consumption-Based ROL’s or the Average Monthly

Consumption. As a result the study concluded that staff

relied on their working experience to determine the

quantities to be ordered (Matse, 2005b).

114
The lack of utilisation of proper ordering systems further

contributed to drug stock outs and the district once again failed

to comply in the implementation of adequate stock control

systems.

5.4.3 Availability of tracer and non-tracer items

 Both tracer and non-tracer items required by various

clinics were either in short supply or altogether missing

from the medicine store due to the reasons already

mentioned above. Hence, at some clinics patients did not

always receive medication.

 Due to poor inventory control, there were frequent stock

outs which varied from one PHC clinic to another.

5.4.4 Stock take

 Stock take was also not conducted regularly in 68% of the

clinics. This is a major contributing factor to over or under

ordering since the facility has no idea as to what drugs to

order. This is also a major contributor to out of stock

and/or expired stock situations contributing to patients not

receiving medication.

115
5.4.5 Responsibility for ordering of medication

From the study it was established that PA’s were mostly

responsible for ordering of medication. Thirteen clinics did not

order medication when PA’s rotated to other clinics. It can also

be assumed that no record-keeping took place in the absence of

an assistant, since there was no dedicated allocat ed person for

DSM in the absence of a PA.

5.4.6 Expired stock

 The value of expired stock was high at some facilities. The

study found that principles of FEFO and FIFO were not

adhered to in some clinics, contributing to the high value

of expired stock. The lack of adherence to ROL’s could

also have been a contributin g factor to expired stock.

5.4.7 Delivery of medication

 There was no dedicated transport in terms of vehicles and

drivers. Transportation of drugs at various levels was done

by a car and deliveries of a single order were often split.

The transport department could not adhere to the delivery

roster, which resulted in drugs not being delivered on time

to the clinics. This contributed to out of stock situations.

According to a study conducted by Matse, transport of

116
 medication has been cited by many studies as one of the

major problems affecting the distribution of drugs (Matse,

2005b). This is definitely a contributing factor in the

Sedibeng district to the drug out of stocks at PHC level.

5.4.8 Visit by the district pharmacists

There was a lack of monitoring and evaluation by district

pharmacies as pharmacists did not manage to visit all clinics

each month. The W HO (2003) cites reliable supervisory systems

as one of the key elements of an effective distribution

management of drugs. Findings according to the Matse study

indicated that all parties involved in the management of drugs

must play their part and work together to improve supply chain

management and reduce drug shortages (Matse, 2005 b).

5.4.9 Availability of SOP’s and standard reference material

 There was no EDL, SOPs and STG’s in some of the PHC

clinics. This could have contributed to out of stock

situations since the EDL is used as a guideline for the

ordering of drugs. The STG assists in rational prescribing

and usage of drugs. SOPs assist with the usage of

formulas for ROL’s, the ordering and receipt of drugs

including cold chain management.

117
The fourth objective of the study was:

To identify if stock control systems were in place to ensure

affordable and acceptable drugs at PHC level.

The objective of this study was met by the results illustrated

above.

 The Sedibeng district failed to meet this objective due to

not adhering to proper stock control procedures. Drug

stock outs varied from three tracer items out of stock at

one clinic and as many as eleven items at another clinic.

The fifth objective of the study was:

To update the current tool to effectively monitor drug supply in

the Sedibeng district (a monitoring and evaluation tool is

currently used from the clinic supervisors manual by the ND OH

to monitor DSM in the Gauteng Province ).

The researcher compared the drug supervisory tool with the

questionnaire used in this study and identified challenges

118
experienced in DSM which were excluded from the supervisory

tool.

The following aspects were not addressed in the supervisory

tool:

 Availability of dedicated trained personnel to manage drug

supply,

 Availability of dispensing licences and section 56A permits

for nurses to dispense,

 The involvement of the transport department in the

distribution process,

 The availability of a secure delivery area,

 The checking of stock immediately upon receipt of

medication delivery,

 The availability of dedicated driver and an appropriate

delivery vehicle,

 Some of the necessary SOP’s and STG’s required at the

clinic were omitted.

 Monthly supervisory visits by the pharmacist.

The implementation of the NCS will address and overcome a

number of the challenges identified in the supervisory tool.

119
There are definitely gaps between policy and practice in primary

health care and improving primary level health services is

notoriously slow. In order to improve DSM, a situational

analysis is essential in identifying problem areas. Clear joint

leadership and vision from management is imperative to

facilitate implementation of recommendations based on

identified challenges (Barron & Monticelli, 2003).

The key to safe and appropriate management of medicines is a

coordinated approach that supports and encourages continuity

in all areas of the community and the health care sector. There

are three essential components for ensuring the quality use of

medicine across the health care system.

 The first is to establish standards of practice that

define SOP’s.

 The second is to identify the positions or persons,

working within the accepted limits of their roles, who

are responsible for implementing each step of the

process.

 Lastly a constant monitoring and evaluation system to

ensure processes are implemented and followed.

120
The DOH continues to add new services to PHC without the

addition of resources, infrastructure and staff. The role out of

ARV services to all PHC clinics recently is but one example of

this. National and provincial programme managers pass on

policies and requests for tasks to districts without ensuring that

they have the means to implement these (Matse, 2005a).

Policy implementation requires stepwise systems change,

phasing of interventions, and rationalisation of resources. The

details of systems are not explicitly set out in the policy. An

example of this is that the requirement of a vehicle to deliver

medication on a daily basis to all clinics is often overlooked.

The DOH needs to plan for implementation in a detailed manner

and to track loopholes along the way. The role of the Provincial

DOH is not only to dictate change but also to support change

through providing clear guidelines, unpacking the policy for the

particular district and providing extra resources if and where

necessary. Close monitoring of a new system and ongoing

problem-solving is important.

The DOH needs to establish a benchmark against which health

establishments can be assessed, gaps identified, and strengths

121
appraised. It needs to provide a national framework to certify

that health establishments are compliant with standards.

The introduction of the NCS is one such frame work. The NCS

correspond with the NDOH’s strategic plan for 2009/2012, and

the 10-Point Plan of 2009-2014, which highlights “improving the

quality of health services” and “the establishment of a quality

management and accreditation body” respectively.

The NCS will benefit pharmaceutical services by increasing

awareness of pharmacy issues in the general health care arena;

encourage staff to work together in multidisciplinary teams

within facilities, and to provide a useful means of monitoring

progress over time.

Due to the fact that this study did not include DSM at the

district pharmacy; further studies will have to be conducted to

establish factors affecting DSM at the Sedibeng district

pharmacy.

The study found that each PHC clinic experienced different

challenges and collectively these factors contributed to

medication not being available according to the 99.5%

122
requirement at all times. None of the clinics were found to be

totally compliant in terms of the objectives of this study.

In conclusion this study found that the DSM cycle in Sedibeng

district is not meeting all requirements. However, the findings

were consistent with previous studies and factors affecting DSM

correspond to previous studies in terms of DSM at PHC centres.

The MEC for Gauteng Health will be notified of these results as

he directed monitoring and evaluation teams to ensure drug

availability of 99.5% stock levels at all times.

This chapter summarised key results obtained from the study.

The next chapter will address key recommendations based on

the outcome of the study.

123
 CHAPTER 6

KEY RECOMMENDATIONS

This chapter outlines recommendations to improve DSM in the

Sedibeng district based on the findings of the study.

SECTION A

6.1 HUMAN RESOURCES

A dedicated person needs to be appointed at each clinic that

will be responsible for DSM preferably PA’s, thus ensuring that

all clinics have a full time PA on a permanent basis. Currently,

the Sedibeng district has embarked on training twenty students

as PA’s. Pharmacy management has recommended that a two

year contract be implemented to ensure a minimum period of

retention upon completion of training.

6.1.1 Training

It is recommended that on the job training for store managers,

PA’s and nurses in basic stores and drug management be

provided. This training should be compulsory and ongoing. The

implementation thereof needs to be monitored. Job descriptions

of designated people for drug supply should include duties of

124
DSM and quarterly performance evaluations should include DSM

evaluations.

The Sedibeng district needs to ensure that that nurses who

dispense and manage drugs are in possession of a dispensing

licence.

SECTION B

6.2 INFRASTRUCTURE AND SECURITY

6.2.1 Storage of medication and condition of a medicine

store and a secure delivery area

Proper storage space for a medicine store should be provided

with adequate shelving, ventilation, light and temperature

control systems at all levels. A secure delivery area also needs

to be ensured at every clinic. Facility planning needs to be

involved together with senior management and the pharmacy

department. The necessary infrastructure needs to be budgeted

for and the pharmacist should insist on delivering a service in a

suitable environment. Facilities should comply with GPP

requirements (SAPC, 2010). The SAPC can also be consulted to

ensure management support.

125
6.2.2 Temperature control in the medicine store and

consulting room

All clinics need air conditioners which are functional together

with a service plan to ensure that the air conditioners are

regularly maintained.

6.2.3 Pest infestation

A pest control policy should be made available together with a

service provider for regular inspection and fumigation if

necessary.

6.2.4 Access control and security in the medicine store

 All clinics need to ensure that the key for the medicine

store is in the possession of an authorised prescriber as

prescribed according to GPP standards (SAPC, 2010).

 A key register also needs to be implemented to ensure that

the keys are only available to authorised prescribers of

medication.

 All medicine cupboards need to be locked when it is not

being used.

126
6.2.5 Delivery and receipt of medication

 A dedicated staff member should be responsible for

receiving and checking of medication. Medication needs to

be checked within 24 hours and the facility needs to be

accountable for all shortages of drugs.

 The transport department needs to be trained on the

importance of ensuring that documentation is signed upon

delivering of medication and ensure that the physical stock

corresponds to the delivery note. The clinic together with

the transport department needs to report shortages

immediately to the district pharmacy and the relevant

department needs to be held accountable. The district

pharmacy together with management support need to take

disciplinary measures if there is non -compliance in this

with regards to these procedures at PHC level.

 Communication between the transport department, the

district pharmacy and PHC clinics, in terms of delivery and

receipt of medication needs to be strengthened.

 The Sedibeng district needs to budget for and provide a

separate vehicle and a designated driver for the

transportation of drugs at different levels. Failure to

address this issue will result in continuous out of stock

127
 situations at clinics as medication will not be delivered on

time to clinics.

 The district needs to consider the aspect of reducing loss

and pilferage by implementing a security system across the

supply chain.

6.2.6 Cold chain management

Overall cold chain management was maintained in the district

but clinics without generators need to have a contingency plan

in place in the event of a power failure. A monitoring system

such as an alarm in the event of a power failure after hours

needs to be implemented.

SECTION C

6.3 MEDICINE MAN AGEMENT AND PROCESSES

6.3.1 Inventory control systems

Currently the PHC clinics in the Sedibeng district have a

manual drug ordering system. The district needs to consider

and plan for an automated logistics information management

system that tracks stock levels and consumption patt erns,

making the inventory transparent through out the system.

128
6.3.2 Availability of bin cards

The FM should be assigned to introduce and encourage the staff

members to be more organised and to use stock cards (bin

cards) for the medicine store along with the maintenance and

regular update of the stock register and other records.

6.3.3 Method of calculation of drug ordering quantities

 Appropriate methods for quantifying drug requirements

based on actual need should be utilised at clinics in the

Sedibeng district i.e. on past consumption, morbidity or

combination of all these. In service training together with

monitoring on a monthly basis will assist in the

implementation of this process.

 A control system that allows decisions on ‘when to re -

order’ and ‘how much to order’ should be introduced. The

ROL calculation should be efficient. In service training will

assist in addressing the correct calculation of ROL’s.

6.3.4 Availability of tracer and non -tracer items

 The availability of all vital and essential drugs at all levels

of health care delivery systems should be ensured. One of

the limitations of this study was the exclusion of the

district pharmacy and its suppliers in the sample. Further

129
 research needs to be conducted to establish whether there

are any bottlenecks in this supply chain.

 Use of buffer and safety stock for maintaining a desirable

service level which can deal with emergency situations

should be introduced at district level. This would allow for

less out of stock situations to arise.

6.3.5 Stock take

A monthly stock count prior to ordering needs to be

implemented and monitored by the FM. Evidence of stock count

and stock take needs to made available and FM’s need to be

held accountable for non-compliance. In service training should

also be conducted to assist in understanding the importance of

stock take.

6.3.6 Responsibility for ordering of medication

A dedicated person needs to be appointed to ensure that

medication orders are placed according to the order roster from

the district pharmacy. Currently whilst PA’s are still being

trained, a joint effort is required by facilities managers, PA’s

and nurses to ensure implementation of proper stock control

procedures until such time that each clinic has a dedicated staff

member to manage drugs on a regular and permanent basis.

130
6.3.7 Expired stock

Implement a system to track expiry dates at PHC clinics,

thereby minimizing expired stock. The implementation of the

NCS requires the introduction of an expiry register at each

facility. This is mandatory and will be monitored by the National

Health Team together with pharmaceutical services.

6.3.8 Feedback from the district

 The communication gaps between the district pharmacy and

PHC clinics needs to be strengthened thereby ensuring

that PHC facilities are informed of drug delivery dates, out

of stock drugs, short dated stock, protocol changes, etc.

This can be implemented by attending the monthly FM’s

meeting and ensuring that pharmacy becomes a permanent

feature on the agenda.

 The FM’s need to ensure communication from the meeting

is filtered down to the appropriate person.

 Telecommunication tools can also be used to inform

facilities of the status of various drugs.

6.3.9 Visits by the district pharmacists

Appoint more pharmacists at the Sedibeng district to ensure

proper monitoring and evaluation of PHC clinics. Community

131
service pharmacists could also assist by completing their

community service in a PHC clinic.

6.3.10 Availability of SOP’s and standard reference material

 The district pharmacy needs to ensure that all clinics have

the necessary SOP’s and reference material available.

 PHC facilities need to ensure the availability of SOP’s and

standard reference material as these are often not kept

safely and need to be issued year after year.

The fifth objective of the study was:

 To update the current tool to effectively monitor drug

supply in the Sedibeng district (a monitoring and evaluation

tool is currently used from the clinic supervisors manual by

the NDOH to monitor DSM in the Gauteng Province ).

The supervisory tool which is currently used in the Sedibeng

district needs to be reviewed and updated to incorporate all the

aspects of DSM which were found to be a challenge in this

study. Currently, the tool does not address the issue of human

resources and training. A task team which consists of area

managers for PHC clinics, the district pharmacists and FM’s

should be involved in this review. Monitoring and evaluation

132
should be mandatory at least once a month for each clinic and

the findings need to be reported and recorded.

The updated DSM section of the tool needs to be used by

pharmacists during supervisory visits. The Clinic Supervisory

tool (DOH, 2003), if used correctly, could create the following

situations:

 Ensure that clinics are consistently monitored and

resources are in place,

 Ensure adequate amount of staff with appropriate skills

 Ensure that drugs, clinical supplies and equipment are

adequate

 Ensure procedures, guidelines, norms and standards are

followed

 A maintained infrastructure is ensured.

After every supervisory visit, pharmacists should present their

findings and make recommendations regarding the

implementation of these, based on a realistic time frame.

Progress can be tracked on a monthly/quarterly basis. This

process is only possible through a joint effort by management of

different departments. The results of the monitoring and

133
evaluation should be accompanied by an action list attaching

responsible staff members to various actions identified. This

needs to be reviewed monthly or quarterly. Challenges

identified in the action list need to be esca lated to senior

management to assist in addressing identified gaps.

By implementing these recommendations, the Sedibeng district

should be able to address the challenges identified in this

study. This should improve drug availability and ultimately

improve patient care at PHC level.

134
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145
APPENDIX 1:

UNIVERSITY OF LIMPOPO (Medunsa Campus) CONSENT FORM

Statement concerning participation in a /Research Project*.

Name of Study:

“Problems affecting drug supply management at primary health care level in the

Sedibeng district”

I have read the information the aims and objectives of the proposed study and was

provided the opportunity to ask questions and given adequate time to rethink the issue.

The aim and objectives of the study are sufficiently clear to me. I have not been

pressurized to participate in any way.

I understand that participation in this Study is completely voluntary and that I may

withdraw from it at any time and without supplying reasons.

I know that this Study has been approved by the Medunsa Research Ethics Committee

(MCREC), University of Limpopo (Medunsa Campus) /Sedibeng district. I am fully

aware that the results of this study will be used for scientific purposes and may be

published. I agree to this, provided my privacy is guaranteed.

I hereby give consent to participate in this Study.

............................................................ .................................................

Name of participant Signature of participant

.............................. ………….. .................................................

Place Date Witness

______________________________________________________________________

146
Statement by the Researcher

I provided verbal information regarding this Study

I agree to answer any future questions concerning the Study as best as I am able to.

I will adhere to the approved protocol.

................................ ..................... ...................... ...........................

Name of Researcher Signature Date Place

147
APPENDIX 2:

INFORMED CONSENT FORM

I hereby confirm that I have been informed by the researcher, Ms Shamima Tayob

about the nature and benefits of the study entitled:

“Problems affecting drug supply management at primary health care level in the

Sedibeng district”

I have also received, read and understood the above written information (Participant

Information Leaflet and Informed Consent) regarding the study.

I am aware that the results of the study will be anonymously processed into a study

report.

In view of the requirements of this research, I agree that the data collected during this

study can be processed in a computerised system by The Sedibeng district Pharmacy

or on their behalf.

I may, at any stage, without prejudice, withdraw my consent and participation in the

study.

I have had sufficient opportunity to ask questions and (of my own free will) declare

myself prepared to participate in the study.

148
PARTICIPANT

Printed Name Signature / Mark Date and Time

I, Shamima Tayob, herewith confirm that the above participant has been fully informed

about the nature of the above study.

RESEARCHER

Printed Name Signature Date

149
APPENDIX 3
QUESTIONNAIRE TO TRANSPORT OFFICER

1. Is there a dedicated driver to deliver medication ? Yes No

2. Is there a dedicated vehicle to deliver medication? Yes No
No
3. What type of vehicle do you use to Closed Van Open Car Other- specify.
transport medication? van
4. Does the order fit into the vehicle at once? Always Sometimes Orders have to be split
5. If the order is split, do you deliver the balance the Sometimes Always Never
same day?

6. Do you have a schedule which you follow to deliver medicine from district Yes No
pharmacy to the PHC clinic?
7. Are you always able to adhere to the delivery schedule ? Yes No
8. Are security personnel always available to count the number of Always Sometimes Never
boxes?
9.items which
Is there are loaded
a dedicated into the
person vehicle?
to receive the order when it delivered to the clinic? Yes No

10. Who is the person receiving the order at Store manager Facility Security Other
the clinic? Manager
11. Are the number of the boxes checked immediately when Sometimes Always Never
the delivery is received at the clinic?
12. Please explain what happens if the what procedure is followed if the order is not checked immediately.

13. Is there an accompanying delivery note with each order? Yes No

14. Is the order checked against the delivery note in your presence? Yes No
15. Explain what action is taken if the order does not correspond to the delivery note

16. Is the delivery note signed by the person receiving the order? Yes No

17. Do you return a copy of the signed delivery note to the pharmacy? Yes No
18. In your experience, have there been discrepancies in terms of delivery of Yes No
medication?
19. Is the cold chain maintained when delivering Sometimes Always Never
medication?
20. If the cold chain is not maintained, who do you report Do not PHC clinic District
this to? report Pharmacy

150
 APPENDIX 4: QUESTIONNAIRE TO FACILITY MANAGER AND /OR STORE MANAGER

SECTION A –FACILITY MANAGER

Reference (Unique Completion Date: District:
No.):
1. Name of Facility Name of Sub-district:

2. Facility Type a. Community b. Primary Health

Health Centre Clinic e. Other(s) (specify): ________________

HUMAN RESOURCES

3. Is there a specific person responsible for Yes No Designation

medicine supply management ?
4. If there is no dedicated person to manage drug supply, please explain how drugs are managed at the facility.

TRAINING DETAILS
Please indicate number of staff who have been trained in dispensing.

5a. PHC nurses No. trained: No. in training: No .untrained:

b. Pharmacist Assistants. No. trained: No in training: No. untrained:

6. No. of people that have received training in DSM in No=

the last twelve months

Additional Comments:
management over the last 12 months

SECTION B- FACILITY MANAGER/STORE MANAGER

INFRASTRUCTURE AND SECURITY
7.a Indicate areas where medicine is Pharmacy Medicine Nurses consulting Other
stored Store Room
8. Is the storage area large enough to store all the stock for a month’s supply? Yes No
9. Are only medicines stored in the areas mentioned above? Yes No
10. Are there any cracks, holes in the wall’s in the area’s where medication is stored? Yes No
11. Is the ceiling in a good condition in the area where medicine is stored? Yes No
12. Is there a secure delivery area for medication? Yes No
13. Is the medicine store protected from Curtains none Other
sunlight by means of the following? Blinds paint
14. Is the medicine room free from any signs of pest infestation (i.e. cockroaches, rats , Yes No

151
ants)?

15. Is the access to the pharmacy by unauthorised persons Yes No

controlled?
16. Who has the key for the medicine store/ pharmacy? Pharmacist Other nurses

( Tick the relevant category/categories of staff) Pharmacist assistant Cleaner

Sister in charge Other

17. Available
Security
Systems a. CCTV b. Alarm c. Guard d. Burglar bars e. Security door

FACILITY MANAGER/STORE MANAGER SECTION C

STORAGE AND CONTROL PROCESSES

18. Which of the following Check number of boxes Check stock received Other No procedure
receiving procedure/s apply at this and sign driver’s note against invoice
facility?
19. Who is responsible for Pharmacist Pharmacist Nurse Store Security Other
receiving drugs in the facility? assistant manager

20. Within what period of time is stock Immediately The same day Within 24 hours Later
checked after receipt ?

21. Are medicines packed according to the FEFO principle? Yes No

22. Are there any drugs stored in direct contact with the floor? Yes No

23. Which option describes the Medicine Pharmacy Consulting M/R P C/R M/R P C/R
ventilation process / temperature Room (P) room (CR )
control of the Pharmacy/Medicine (M/R )
store best?
Air Conditioner (functional) Fans Air bricks
24. Is the room temperature recorded twice daily? Yes No

Additional comments:

COLD CHAIN MANAGEMENT AND STORAGE.

25a. Is only medicines stored in all the designated medication fridges and refrigerator (no food, Yes No
no drinks)?
b. Is there sufficient space in the refrigerator/cold room to store medication and provide adequate Yes No
flow?
c. Is there a thermometer in the fridge? Yes No
of cool air?

152
d. Is the temperature of the refrigerator(s) maintained between 2C and 8C? Yes No

e. Is the temperature recorded twice daily? Yes No

f. Are fridges defrosted and cleaned twice a month or when the ice is more than 5mm? Yes No
g. When there is a power failure, is there a backup generator in case of a power failure? Yes No

h. Is the cold chain maintained when receiving stock from the district pharmacy? Yes No

Additional comments:

153
 SECTION C- FACILITY MANAGER/STORE MANAGER

Medicine Management and Processes.

26 Indicate which inventory Manual/Paper Based Computerised None

Management/Stock Control system is used.
27. Are bin /stocks available in the facility Consulting Updated Medicine Updated
for tracer items? room room

Yes No Yes No Yes No Yes No

28. Which of the following is reflected on Max stock level Average Monthly Reorder
the stock card/computer? Consumption level/factor

29. Has the ROL been calculated for all tracer items in the Yes No
store?
30. Are the re-order levels of tracer items reviewed? Yes No If yes how often

31. What was the average stock out period of tracer items? 1-3 days 4-7 days 8 days or more

32. Are there any items out of stock currently Yes No No of items=
according to the tracer list tracer list?
33. Who is responsible for ordering Pharmacist Pharmacist Nurse Store manager Other
of medication in the facility? Assistant

34. Did any drugs expire over the last 12 months? Yes No

35. If yes what was the estimated monetary value of the items R Don’t Know
expired?

36. How does the supply system track expiry date? Please explain

37. When was the last stock take conducted? Date:

38. What is your lead time between request and No of day’s: Don’t Know
receipt of drugs?

39. Do you receive your order on time from the district Yes No Sometimes Most of the time
pharmacy?
40. What action is taken if orders Contact Contact Other
are not received on time? pharmacy Transport
41. Do you report on stock out Yes No For All For Tracer To Whom-
situation? Medicines Medicines
42. If the facility is out of stock of medication, what do you do? Please choose the most appropriate
answer/s below
do you:
a. Do you send patients to other clinics? Yes No

b. Do you borrow from other clinics? Yes No

c. Do you substitute medication if possible? Yes No

d. Do you send the patient without medication and ask them to come back? Yes No

154
e. Do you give patient a small supply and ask them to come back? Yes No

f. Do you tell the patient that there is no medication at clinics and you are not Yes No
sure when you will receive medication?
43. Do you receive feedback Expected Out of stock in Status of to follow orders
regarding the status of your orders? delivery pharmacy
Yes No Yes No Yes No
44. Are all procurement and receipt documents filed? Yes No

45. List three main reasons why you experience

yes nostock out?
yes no yes no
a.

b.

c.

46. Is medication stock out addressed within 48 hours? Yes No

If not –please explain why?

47. Has the facility been visited by the district pharmacist in the last month? Yes No

155
APPENDIX 5 : RESEARCHER CHECK LIST
Reference (Unique 1.Completion Date: Name of facility
No.):
2. Check area’s where
medicines are stored a. Pharmacy b. Dispensary c. Bulk Store d. Nurse Consulting room
3. Is only medicine stored in areas identified in Question 2. Yes No

4. If the answer to Q3 is no –please identify what else is Other items-

stored in the medicine store medicine store
5.Check for availability of dispensing licence/ NA Dispensing licecence Section 56A Certificate
SECTION 56A certificate Yes No Yes No
6. Check for availability of section 38a or a section 56a permit to dispense medicines NA Yes No

STORAGE OF MEDICATION: Chart available Chart updated

7. Check availability of the temperature Medicine Consulting Medicine Store Consulting
chart in Medicine room / consulting Store room Room
room Yes No Yes No Yes No Yes No
8. Check if there are expired items in the Medicine Pharmacy Consulting rooms
facility store
9. Check if medicines are packed according to FEFO Medicine Store Consulting Room
principle Yes No Yes No
10. Check if there are no damaged containers or packages Medicine Store Consulting room
on the shelves?
Yes No Yes No

11. Check the number of items out of stock Tracer items Non tracer Items
No= No=
12. Check the value of expired stock for the last three Value
months
Yes No Yes No
13. Check that there are no supplies stored in direct contact Medicine store Consulting room
with the floor Yes No Yes No

14. Check for evidence of stock take in facility Medicine room Consulting room Frequency=
Yes No Yes No
15. Check if bin cards for tracer items are Medicine Room Consulting room Updated regularly
available and updated Yes No Yes No Yes No
16. Check if each tracer item has a Medicine Room Consulting Reviewed three monthly
re-order level room
Yes No Yes No Yes No
17. Check if only medicines are stored in the refrigerator (No food, no drinks) Yes No
a. Check if the temperature of the refrigerator(s) is between 2C and 8 Yes No
b. Check if fridges are clean and ice is less than 5mm thick Yes No

c. Check if a temperature chart is available and up Chart available Chart updated twice daily
to date Yes No Yes No
Record available Ice less than 5mm thick
d. Check if cleaning records are available Yes No Yes No
for fridge
18. Check documents for procurement and receipt of medication Available Not available Filed
Yes No
19. Check order files to determine if stock is Stock counted for all Re-order level recorded for each item
counted prior to ordering and re-order levels items
indicated of each item on order file Yes No Yes No

156
 STANDARD OPPERATING PROCEDURES AND REFERENCE MATERIAL
20. Check if the following SOP’s are available in the facility ( Addendum 1 of Circular 4 of 2007 )

a. Control of access to dispensary or medicine room Yes No

b. Designation of the medicine room Yes No
c. Issues to the district from the regional pharmacy Yes No
d. Organisation of medicine room Yes No
e. Security in medicine room Yes No
f. Receipt and storage of medicine Yes No
g. Issues from medicine room to consulting rooms Yes No
h. Borrowing of medicine between institutions Yes No
i. The use of stock cards (VA 11) Yes No
j. Stock taking in medicine and consulting rooms Yes No
k. Product types requiring special handling and storage Yes No
l. Cold chain management Yes No
m. Checking and return of expired/obsolete/unusable and patient return stock to the district Yes No
pharmacy
n. Complaints of product quality and adverse drug reactions Yes No

21. Check if the pharmacy/facility has copies of, or electronic access to: Yes No
a. EDL/STG - Adult Standard Treatment Guidelines for Hospital Edition/
date
b. EDL/STG - Paediatric Standard Treatment Guidelines for Yes No
Hospital
c .EDL/STG - Primary Health Care Standard Treatment Guidelines Yes No
d. A Provincial Formulary/Code List Yes No

No

157
APPENDIX 6: TRACER MEDICINES MONITORING – Primary Health Care

Reference (Unique No.): Date: District

3. Sub District:
2. Name of Facility:

Recorded Physical Qty

No. Generic Name Route Form Stock Stock Expired

1 Adrenalin 1mg/ml IM
Amp

2 ARVs (all) Oral Tab or Susp

3 Cefixime 400mg Oral Caps

4 Ceftriaxone 250mg or 1g IV Vial

5 Diazepam 5mg/ml IV/IM Vial

6 EPI Vaccines (all) IM Vial

7 Insulin Soluble 100IU/ml all IM Vial

Norethisterone 200mg/ml or
8 IM Vial
Medroxyprogesterone 150mg/ml
9 Salbutamol Inhaler 200 doses INH Spray

10 Sodium Chloride 0.9% IV Vial

11 TB Medicines (all) Oral Tab

12 Amoxicillin 125mg/ml Oral Susp

13 Amoxicillin 250mg or 500mg Oral Caps

14 Co-trimoxazole 25mg/ml Oral Susp

15 Co-trimoxazole 480mg or 960mg Oral Tab

16 Hydrochlorothiazide 12.5mg or 25mg Oral Tab

17 Ibuprofen 200mg Oral Tab

18 Metformin 500mg or 850mg Oral Tab

19 Oral Rehydration Salt (ORS) Oral Sachet

20 Paracetamol 24mg/ml Oral Susp

21 Paracetamol 500mg Oral Tab

158
APPENDIX 7:

GLOSS ARY

Auxiliary Worker Pharmacy - Refers to workers who are at

different phases of training as pharmacist assistants and can

practice according to guidelines set about by the SAPC

depending on the stage of training.

Community service pharmacist - is a qualified pharmacist but

is obliged to practice for a period of a year in the public sector

as prescribed by the SAPC.

Consumption based estimates - Prediction of future drug

requirements on the basis of historic information on drug

consumption.

Cross-sectional studies- involve data collected at a defined

time. Cross-sectional studies may involve special data

collection, including questions about the past, but they often

rely on data originally collected for other purposes.

Descriptive research- involves gathering data that describe

events and then organizes, tabulates, depicts, and describes

159
the data collection. It often uses visual aids such as graphs and

charts to aid the reader in understanding the data distribution .

District Health - A district health system is the vehicle for

providing quality primary health care to everyone in a

defined geographical area. It is a system of health care in

which individuals, communities and all the health care

providers of the area participate to gether in improving their own

health.

Drugs/Medicines/Medication - a drug taken to cure and/or

ameliorate any symptoms of an illness and the words.

Drugs/Medicines/Medication will be used interchangeably for

the purposes of this study.

Drug supply management at PHC - Means the procurement,

appropriate storage, in a specific order separating different

dosage forms, monitoring expiry dates, maintaining cold chain if

applicable, having bin cards with each item having the name,

reorder level, code number, date received and issues always

recorded, stored off the floor in a lockable store room where the

temperature is controlled, monitored and recorded twice daily.

160
General assistant - is one who works in the pharmacy but has

no formal training with regards to pharmacy and is not allowed

to be in direct contact with medication. General assistants

assist with cleaning and other non pharmaceutical duties.

Generic - Is the official medical name for the active ingredient

of the medicine.

Facility - Overall PHC activities and personnel in one local

PHC.

Facility manager - A personnel appointed, delegated or

assigned to manage.

Maximum stock level - this level is the target level which is the

stock needed to satisfy demand until the next order after this

one is received.

Medicine room - Is a secure, organized, temperature controlled

room within a primary health care clinic, designated for use of

the storage of bulk stocks of medi cines, which must comply with

the minimum standard supply of medicines in a primary health

care clinic (refer rules1.6.2-1.6.7 of the Good pharmacy

161
practice rules published in terms of Section 35A of the

pharmacy act of 1974). No dispensing of medicines for patients

may be done in a medicine room.

Nursing Act No 33 of 2005 - The prescribing and dispensing

practices of registered nurses in accordance with the provisions

of the Medicines and Related Substances Act No. 101 of 1965,

as amended ("the Medicines Act") and the Nursing Act No. 33 of

2005 ("the Nursing Act"). A registered nurse must, obtain prior

authorisation from the South African Nursing Council ("the

Nursing Council") in order to be able to prescribe Scheduled

substances.

This authorisation is obtained from the Nursing Council in

accordance with the provisions of section 56(1) of the Nursing

Act, which is dealt with in detail below; to compound and

dispense the Scheduled substances only if he or she has the

requisite dispensing licence to do so.

A registered nurse must apply to the Director -General of the

Department of Health ("the Director -General") in terms of

section 22C of the Medicines Act in order to acquire a

162
dispensing licence. The Director-General will only issue a

dispensing licence to the registered nurse once the nurse has -

 Made payment of the prescribed fee for this license; and

 Successfully completed a supplementary course

determined by the South African Pharmacy Council ("the

Pharmacy Council") after consultation with the Health

Professions Council of South Africa, the Allied Health

Professions Council of South Africa and the Nursing

Council.

In terms of section 56(6) of the Nursing Act, a registered

nursing practitioner is only permitted to prescribe medicines

and Scheduled substances to patients in on -site clinics if -

 he or she has been authorised to do so by the medical

practitioner who is in charge of the specific on -site clinic.

The medical practitioner is required to have consulted with

the Nursing Council prior to the issue of such an

authorisation to the registered nurse. The medical

practitioner is required to complete an authorisation form

which permits the specific nurse to diagnose and prescribe

medicines for the specific treatment protocols that have

been indicated by the medical practitioner on the form;

and

163
  only if the medical practitioner is not personally available

at the on-site clinic in order to diagnose the patient and

prescribe and dispense the requisite medicines (provided

the medical practitioner is in possession of a dispensing

license).

Nursing Act No. 50 of 1978, Section 38A - Special provisions

relating to certain nurses. Notwithstanding the other pro -visions

of this Act and the provisions of the Medicines and Related

Substances Control Act, 1965 (Act No. 101 of 1965), of the

Pharmacy Act, 1974 (Act No. 53 of 1974), and of the Medical,

Dental and Supplementary Health Service Professions Act, 1974

(Act No. 56 of 1974), any registered nurse who is in the service

of the Department of Health, Welfare and Pensions, a provincial

administration, a local authority or an organization per forming

any health service and designated by the Director -General:

Health, Welfare and Pensions after consultation with the South

African Pharmacy Board referred to in section 2 of the

Pharmacy Act, 1974, and who has been authorized thereto by

the said Director-General, the Director of Hospital Services of

such provincial administration, the medical officer of health of

such local authority or the medical practitioner in charge of

164
such organization, as the case may be, may in the course of

such service perform with reference to:

(a) The physical examination of any person;

(b) The diagnosing of any physical defect, illness or deficiency

in any person;

(c) The keeping of prescribed medicines and the supply ,

administering or pre-scribing thereof on the prescribed

conditions; or

(d) The promotion of family planning, any act which said

Director-General, Director of Hospital Services, medical officer

of health or medical practitioner, as case may be after

consultation with the council determine in general or in a

particular case or in cases of a particular nature: Provided that

such nurse may perform such act only whenever the services of

a medical practitioner or pharmacist, as the circumstances may

require, are not available.[S. 38A inserted by s. 2 of Act No. 71

of 1981.]

Out of stock - According to circular 39 of 2005 an out of stock

item maybe defined as the complete absence of an item that

needs to be available. Thus all pack sizes of the item (pre -

packs and bulk) is unavailable .

165
Primary Health Care - A set of prescribed services, generally

falling within the skill base of professional nurse, technician,

mid level worker, counsellor, community health worker, midwife

and emergency medical practitioner. These services may be

first point of contact or follow up.

Pharmacist - Provides pharmaceutical care by taking

responsibility for the patient’s medicine related needs and

being accountable for meting these needs.

Pharmacist assistant - Is one who has undergone two years of

in service training and is allowed to dispense from schedule 1

to 6 under the direct supervision of a pharmacist . In the public

sector, a pharmacist assistant is allowed to dispense under

indirect supervision at PHC clinics under specific pre -

conditions. The PA is then supervised from a distan ce by the

pharmacist.

Pharmacist intern - A pharmacist intern is one who has

completed four years of theoretical study and will apply this

theoretical knowledge in order to gain practical experience

which extends over a period of twelve months. This is a

166
structured practical training programme provided by the SAPC

under the direct supervision of a pharmacist.

Quantitative Research - Research which examines phenomena

through numerical representation of observations and statistical

analysis. Research is quantitative when it measures, compares

and generalizes its findings.

Re-order level - The reorder level is the quantity of remaining

stock that should trigger a reorder of the item. In the minimum

and maximum stock ordering system, this is c alled the minimum

stock level.

Retrospective data - In the case of a retrospective study, the

investigator collects data from past records and does not follow

future records or patients up as is the case with a prospective

study.

Standard operating procedure - Is a written authorized

procedure which gives instruction steps for performing

operations which must be followed in order to complete a

specific job task safely, with no adverse impact on the

167
environment, and in a way that maximi ses operation and

production requirement.

Store Manager - A store manager refers to a person who is

responsible for the medicine store in the facility. This could be

a pharmacist assistant or a staff member appointed by the

facility manager to manage the drug supply for the facility. The

duties of this person will include but not be limited to ordering

of medication for the facility, filling in of bin cards, monitoring

drug usage, ensuring maintenance of cold chain, maintenance

of the medicine store and issuing of medication to consulting

rooms.

Tracer drugs - Consists of approximately 20 pharmaceuticals

that are selected to evaluate availability of essential products.

The items to be selected for a tracer list should be relevant for

public health priorities and should be expected to be available

able at all times in the level of facilities of interest (e.g. clinics

or hospitals).

Transport officer - is one who is employed by the Department

of Health, who is in possession of a valid driver’s licence and

168
who is authorised to transport medication to designated

facilities.

169
APPENDIX 8:

MEDICINE SUPPLY MANAGEMENT

CHECKLIST
Facility Manager: ___________________

Name of Pharmacist:________________

PHC
FACILITY DATE

[] Tick appropriate box

A. Infrastructure
Y N
Are medicines kept in the storeroom, consulting room or both? Y N

Specify:

Is the temperature in the storeroom kept below 25°C?

Y N

Are working surfaces and shelves where medicines are kept finished with a smooth impermeable
material? Y N

:
Are there separate facilities for washing hands and cleaning equipment?
Y N
Are there tablet counting trays?
Y N
Are they cleaned after every use?
Y N
Is the access to the medicine storeroom controlled for unauthorized persons?
Y N
:
Are waste containers available (in line with the IPC policy)?
Y N
The medicine store is large enough to keep all supplies?
Y N
:
The medicine store is kept locked at all times when not in use
Y N

There are no cracks, holes or sign of water damage in the medicine store
Y N
:
There is a ceiling in the medicine store which is in good condition
Y N
The medicine store is appropriately air conditioned
Y N

The windows are painted in white (or have curtains) and are secured with grills

170
 Y N

There are no signs of pest infestations in the medicine store (i.e. cockroaches, rats)
Y N

The medicine store is tidy; shelves are dusted, the floor is swept, and walls are clean
Y N

Supplies are stored neatly on shelves or in boxes Y N

There are no supplies in direct contact with the floor (boxes are kept in pallets)
Y N

B. Selection
Are medicines prescribed by generic name?
Y N

Are medicines adequately labelled?

Y N

Are medicines prescribed from essential medicines list?

Y N

Is the essential drug list/formulary available to practitioners?

Y N

C. Procurement - Stock cards/ Ordering Supplies

Do you have an SOP for procurement of medicine stock? Y N

Is it signed and dated? Y N

Do you know how to calculate the Average Monthly Consumption (AMC) – ask one to calculate it Y N
then Check Formula

Do you take into consideration stock out period when calculating the AMC Y N

Do you calculate the Maximum Stock by multiplying the AMC by the Maximum Stock Factor Y N

Has the Maximum Stock been calculated for each item in the store Y N

Is the Maximum Stock recorded on each item’s stock card (in pencil) Y N

171
When was the last time that the Maximum Stock was reviewed?

Indicate:
Is a standard requisition form used? Y N
Are all orders placed in writing using the prescribed forms? Y N
Is the requisition book kept at the facility? Y N

Is all information on the requisition form accurate and clearly written? Y N

How often do you place an order?

Explain:
What is your average lead-time?

What is your facility’s reorder factor?

Explain:

D. Distribution
How are stock outs addressed when they occur?

Explain
What is the average length of time of stock out for critical items (tracer medicines)?
Indicate:

How are stock oversupplies handled when they occur?

Explain:
Are quantities received checked against quantities ordered?
Y N

Are safety stock levels determined and adjusted accordingly?

Y N
Do you receive feedback regarding the status of your orders (expected delivery dates for orders
placed, dues out from depot, expected delivery dates for dues out items, etc.)? Y N

Do you know whom to contact in patients of emergencies (stock out)?

Y N

E. Storage
Supplies are systematically classified on the shelves (i.e. by dosage forms or therapeutic class)
Y N

Are generic names used with every medicine?

Y N

Tablets and other dry medicines (e.g. ORS) are stored in airtight containers
Y N

Liquids, ointments and injectables are stored on the middle shelves

Y N

Supplies such as surgical items, condoms and bandages are stored in the bottom shelves
Y N

172
Items are grouped in amounts that are easy to count
Y N

There are no expired medicines in the store

Y N

Medicines are utilised in terms of first expiry first out principle (FEFO)
Y N

Supplies with no expiry or manufacture date are stored in the order received (FIFO)
Y N

Supplies with a manufacture date only are stored in chronological order

Y N

There are no damaged containers or packages on the shelves

Y N

There are no overstocked, or obsolete items on the shelves

Y N

The disposal of medicines is recorded in a separate register and includes the date, time, witness,
value, quantities and reason(s) Y N

NarcotiPrimary health care facility supervisor and psychotropic medicines are in a separate
double-locked storage space Y N

Are items checked regularly for potential deterioration (i.e. bad odour or discoloured tablets)
Y N

Temperature sensitive items are stored in a refrigerator

Y N

The refrigerator is in working condition

Y N

There is no health care personnel food in the refrigerator

Y N

A temperature record is available and up-to-date

Y N

F. Use Y N
Does the labelling of medicines meet the legal requirements? (Supervisor to take 3 random Y N
samples of prescriptions issued to 3 – 5 patients. Tick from the list: Name of patient, name of
medicine, strength and quantity, instructions on how to take the medicine, name of facility, exp
date and batch number)

Is the person dispensing the medicines licensed or registered? Y N

173
Quality Control/ Patient Care
The health care worker checks for poor quality items, such as: -
o Discolouration of medicines,
Y N
o Sediments in medicines
Y N
o Broken and or leaking containers
Y N
o Spoiled labels on medicine containers
o Unsealed and unlabelled medicine containers
Y N
o Expired medicines on shelves
Y N

Excess medicine in facility Intervention

Short dated stock in facility

174
Out of stock medication
out of stock reasons intervention

175
APPENDIX 9:

176
APPENDIX 10:
SEDIBENG
DISTRICT
STOCK CONTROL CARD HEALTH
Note : For every discrepancy on running balance a reason must be supplied with
PHARMACIST signature !

V
A
1
1
FACILITY:...................................... Page no.

ITEM:…………………………….....

RE-
ORDER
STRENGTH :…………………… PACK SIZE:………………. LEVEL:

CODE NO :……….………….. UNIT OF ISSUE:………….

DATE ISSUING STOCK STOCK RECEIVED (Red pen!) RUNNING SIGN

ORDER ISSUED INVOICE
NO TO QTY NO FROM QTY BATCH EXP BALANCE

177
APPENDIX 11:
SHAMIMA TAYOB: 2011 10:45 Wednesday, October 5, 2011 19
PROGRAM FILE SHAMIMA.sas *** DATA FILE DATA Shamima data.xlsx
SECTION A: FACILITY MANAGER
PRINTOUT NUMBER 1

The FREQ Procedure

facility

Cumulative Cumulative
facility Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
Beverly Hills 1 4.00 1 4.00
Boipatong 1 4.00 2 8.00
Boitumelo 1 4.00 3 12.00
Bophelong 1 4.00 4 16.00
Driehoek 1 4.00 5 20.00
EMPILISWENI 1 4.00 6 24.00
Evaton Main 1 4.00 7 28.00
Helga Kuhn 1 4.00 8 32.00
Johan Deo 1 4.00 9 36.00
Johan Heyns 1 4.00 10 40.00
Le Vai Mbatha 1 4.00 11 44.00
Market Ave 1 4.00 12 48.00
Meyerton 1 4.00 13 52.00
Mpumelelo 1 4.00 14 56.00
Osisweni 1 4.00 15 60.00
Pontshong 1 4.00 16 64.00
Retswelapele 1 4.00 17 68.00
Rustervaal 1 4.00 18 72.00
Sharpville 1 4.00 19 76.00
Thlokomelong 1 4.00 20 80.00
Tshepiso 1 4.00 21 84.00
Zone 11 1 4.00 22 88.00
Zone 12 1 4.00 23 92.00
Zone 17 1 4.00 24 96.00
Zone 3 1 4.00 25 100.00

District

Cumulative Cumulative
District Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
Sedibeng 25 100.00 25 100.00

Sub_district

Sub_ Cumulative Cumulative

district Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
Emfuleni 25 100.00 25 100.00

*********************************************************************************
*********************

Facility_type

Facility_ Cumulative Cumulative

type Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
community HC 4 16.00 4 16.00
primary HC 21 84.00 25 100.00

178
*********************************************************************************
*********************
SECTION A: HUMAN RESOURCES
The FREQ Procedure

q3

Cumulative Cumulative
q3 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
yes 25 100.00 25 100.00

Designations

Cumulative Cumulative
Designations Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
Facility manager 1 4.17 1 4.17
assistant 9 37.50 10 41.67
nurse 1 4.17 11 45.83
pharmacist assistant 11 45.83 22 91.67
sister in charge 2 8.33 24 100.00

Frequency Missing = 1

q4

Cumulative Cumulative
q4 Frequency Percent
Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
Part time pharmacist assistant 1 5.26
1 5.26
assistant once a week 6 31.58
7 36.84
assistant twice a week 3 15.79
10 52.63
assistant twice a week or facility manager 1 5.26
11 57.89
full time assistant 4 21.05
15 78.95
pharmacist assistant available on weekly basis 1 5.26
16 84.21
pharmacist assistant twice a week 2 10.53
18 94.74
proffessional nurse 1 5.26
19 100.00

Frequency Missing = 6

*********************************************************************************
*********************

179
 SECTION A: TRAINING DETAILS
PRINTOUT NUMBER 3.1

The FREQ Procedure

nurses_trained

Cumulative Cumulative
nurses_trained Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
0 1 4.00 1 4.00
1 2 8.00 3 12.00
2 9 36.00 12 48.00
3 2 8.00 14 56.00
4 6 24.00 20 80.00
6 1 4.00 21 84.00
7 1 4.00 22 88.00
9 1 4.00 23 92.00
10 1 4.00 24 96.00
12 1 4.00 25 100.00

nurses_in_training

nurses_in_ Cumulative Cumulative

training Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
0 16 64.00 16 64.00
1 6 24.00 22 88.00
2 2 8.00 24 96.00
3 1 4.00 25 100.00

nurses_untrained

Cumulative Cumulative
nurses_untrained Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
0 1 4.00 1 4.00
1 7 28.00 8 32.00
2 7 28.00 15 60.00
3 5 20.00 20 80.00
5 1 4.00 21 84.00
8 1 4.00 22 88.00
9 1 4.00 23 92.00
12 1 4.00 24 96.00
23 1 4.00 25 100.00

*********************************************************************************
*********************

180
 pa_trained

Cumulative Cumulative
pa_trained Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
0 13 52.00 13 52.00
1 12 48.00 25 100.00

pa_in_training

Cumulative Cumulative
pa_in_training Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
0 16 64.00 16 64.00
1 9 36.00 25 100.00

pa_untrained

Cumulative Cumulative
pa_untrained Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
0 25 100.00 25 100.00

q6

Cumulative Cumulative
q6 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
0 22 88.00 22 88.00
1 2 8.00 24 96.00
2 1 4.00 25 100.00

q6_specify

Cumulative Cumulative
q6_specify Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
pharmasist assistant 1 100.00 1 100.00

Frequency Missing = 24

181
APPENDIX 12:

SHAMIMA TAYOB: 2011 10:45 Wednesday, October 5, 2011 24

PROGRAM FILE SHAMIMA.sas *** DATA FILE DATA Shamima data.xlsx
SECTION B: INFRASTRUCTURE AND SECURITY
PRINTOUT NUMBER 4

The FREQ Procedure

q7_1

Cumulative Cumulative
q7_1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
medicine store 21 100.00 21 100.00

Frequency Missing = 4

q7_2

Cumulative Cumulative
q7_2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
nurses consulting room 25 100.00 25 100.00

q8

Cumulative Cumulative
q8 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 19 76.00 19 76.00
yes 6 24.00 25 100.00

q9

Cumulative Cumulative
q9 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 8 33.33 8 33.33
yes 16 66.67 24 100.00

Frequency Missing = 1

q10

Cumulative Cumulative
q10 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 23 92.00 23 92.00
yes 2 8.00 25 100.00

*********************************************************************************
*********************

182
 q11

Cumulative Cumulative
q11 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 1 4.00 1 4.00
yes 24 96.00 25 100.00

q12

Cumulative Cumulative
q12 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 24 96.00 24 96.00
yes 1 4.00 25 100.00

q13

Cumulative Cumulative
q13 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
blinds 8 57.14 8 57.14
none 5 35.71 13 92.86
paint 1 7.14 14 100.00

Frequency Missing = 11

q13_other

Cumulative Cumulative
q13_other Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no store room 1 9.09 1 9.09
no sun inside room 1 9.09 2 18.18
no windows 9 81.82 11 100.00

Frequency Missing = 14

*********************************************************************************
*********************

q14

Cumulative Cumulative
q14 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 2 8.33 2 8.33
yes 22 91.67 24 100.00

Frequency Missing = 1

q15

Cumulative Cumulative
q15 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 2 9.09 2 9.09
yes 20 90.91 22 100.00

Frequency Missing = 3

183
*********************************************************************************
*********************

SECTION B: INFRASTRUCTURE AND SECURITY

PRINTOUT NUMBER 4.1

The FREQ Procedure

Cumulative Cumulative
q16 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
No store room 1 2.38 1 2.38
nurse 1 2.38 2 4.76
other nurses 3 7.14 5 11.90
pharmasist assistant 16 38.10 21 50.00
sister in charge 21 50.00 42 100.00

Frequency Missing = 33

Cumulative Cumulative
q17 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
alarm 2 5.71 2 5.71
burglar bars 11 31.43 13 37.14
guard 6 17.14 19 54.29
locks on cupboards 2 5.71 21 60.00
normal door 2 5.71 23 65.71
security door 12 34.29 35 100.00

Frequency Missing = 40

184
APPENDIX 13:
SHAMIMA TAYOB: 2011 10:45 Wednesday, October 5, 2011 71
PROGRAM FILE SHAMIMA.sas *** DATA FILE DATA Shamima data.xlsx
SECTION C: STORAGE AND CONTROL PROCESSES
PRINTOUT NUMBER 5

The FREQ Procedure

q18_1

Cumulative Cumulative
q18_1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
x 24 100.00 24 100.00

Frequency Missing = 1

q18_2

Cumulative Cumulative
q18_2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
x 24 100.00 24 100.00

Frequency Missing = 1

q19_1

Cumulative Cumulative
q19_1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
pharmasist assistant 21 100.00 21 100.00

Frequency Missing = 4

q19_2

Cumulative Cumulative
q19_2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
nurse 8 100.00 8 100.00

Frequency Missing = 17

q19_other

Cumulative Cumulative
q19_other Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
sister in charge 10 100.00 10 100.00

Frequency Missing = 15

185
 q20

Cumulative Cumulative
q20 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
once a week 1 4.00 1 4.00
the same day 14 56.00 15 60.00
within 24 hrs 10 40.00 25 100.00

q21

Cumulative Cumulative
q21 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 2 8.33 2 8.33
yes 22 91.67 24 100.00

Frequency Missing = 1

q22

Cumulative Cumulative
q22 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 12 48.00 12 48.00
yes 13 52.00 25 100.00

q23_1

Cumulative Cumulative
q23_1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
C/R FAN & WINDOWS 1 4.35 1 4.35
C/R airbricks 1 4.35 2 8.70
M/R aircon 10 43.48 12 52.17
M/R aircon/not working 6 26.09 18 78.26
NONE 4 17.39 22 95.65
aircon 1 4.35 23 100.00

Frequency Missing = 2

q23_2

Cumulative Cumulative
q23_2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
fans 2 66.67 2 66.67
pharmacy AIRCON 1 33.33 3 100.00

Frequency Missing = 22

q23_3

Cumulative Cumulative
q23_3 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
air brick 2 100.00 2 100.00

Frequency Missing = 23

186
 q24

Cumulative Cumulative
q24 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 15 60.00 15 60.00
yes 10 40.00 25 100.00

******************************************************************************************************

q24_comments

q24_comments Frequency Percent

ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
NOT SURE IF AIRCON IS WORKING 1 9.09
a/c remote no batteries 1 9.09
aircon/not working 3 27.27
insufficient shelving, no one to check temperatures if no pharmacist assistant 1 9.09
no aircon 2
18.18
no shelves 1
9.09
no working thermometer 2 18.18

Frequency Missing = 14

SECTION C: COLD CHAIN MANAGEMENT AND STORAGE

PRINTOUT NUMBER 6

The FREQ Procedure

q25_1

Cumulative Cumulative
q25_1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 1 4.00 1 4.00
yes 24 96.00 25 100.00

q25_2

Cumulative Cumulative
q25_2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 8 32.00 8 32.00
yes 17 68.00 25 100.00

q25_3

Cumulative Cumulative
q25_3 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 1 4.00 1 4.00
yes 24 96.00 25 100.00

187
 q25_4

Cumulative Cumulative
q25_4 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 1 4.17 1 4.17
yes 23 95.83 24 100.00

Frequency Missing = 1

q25_5

Cumulative Cumulative
q25_5 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 1 4.17 1 4.17
yes 23 95.83 24 100.00

Frequency Missing = 1

******************************************************************************************************

q25_6

Cumulative Cumulative
q25_6 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 12 48.00 12 48.00
yes 13 52.00 25 100.00

q25_7

Cumulative Cumulative
q25_7 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 19 79.17 19 79.17
yes 5 20.83 24 100.00

Frequency Missing = 1

q25_8

Cumulative Cumulative
q25_8 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
yes 24 100.00 24 100.00

Frequency Missing = 1

q25_comments

q25_comments Frequency Percent

ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
cold chain is ordered twice a week due to power failure and lack of space 1 33.33
fridge not working for past 3 weeks, use cooler box 1 33.33
no thermometer in fridge 1
33.33

Frequency Missing = 22

******************************************************************************************************

188
 SECTION C: MEDICINE MANAGEMENT AND PROCESSES
PRINTOUT NUMBER 7

The FREQ Procedure

q26

Cumulative Cumulative
q26 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
manual/paper base 25 100.00 25 100.00

q27_1

Cumulative Cumulative
q27_1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
reorder level/factor 21 100.00 21 100.00

Frequency Missing = 4

q27_2

Cumulative Cumulative
q27_2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
max stock level 2 100.00 2 100.00

Frequency Missing = 23

q27_3

Cumulative Cumulative
q27_3 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
average monthly consumption 1 100.00 1 100.00

Frequency Missing = 24

q28_1

Cumulative Cumulative
q28_1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
phamasist assistant 20 100.00 20 100.00

Frequency Missing = 5

******************************************************************************************************

q28_2

Cumulative Cumulative
q28_2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
nurse 4 100.00 4 100.00

Frequency Missing = 21

q28_other

189
 Cumulative Cumulative
q28_other Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
facility manager 1 12.50 1 12.50
sister in charge 7 87.50 8 100.00

Frequency Missing = 17

q29

Cumulative Cumulative
q29 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
1 4 17.39 4 17.39
2 2 8.70 6 26.09
3 1 4.35 7 30.43
4 2 8.70 9 39.13
6 4 17.39 13 56.52
7 1 4.35 14 60.87
8 2 8.70 16 69.57
10 1 4.35 17 73.91
11 1 4.35 18 78.26
12 3 13.04 21 91.30
14 1 4.35 22 95.65
16 1 4.35 23 100.00

Frequency Missing = 2

******************************************************************************************************

q30

Cumulative Cumulative
q30 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
1 - 3 days 2 8.70 2 8.70
4 - 7 days 11 47.83 13 56.52
8 days or more 10 43.48 23 100.00

Frequency Missing = 2

q31

Cumulative Cumulative
q31 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 5 20.00 5 20.00
yes 20 80.00 25 100.00

q32

Cumulative Cumulative
q32 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 15 65.22 15 65.22
yes 8 34.78 23 100.00

Frequency Missing = 2

q32_often

190
 Cumulative Cumulative
q32_often Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
3 monthly 6 85.71 6 85.71
monthly 1 14.29 7 100.00

Frequency Missing = 18

******************************************************************************************************

q33

Cumulative Cumulative
q33 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 1 4.00 1 4.00
yes 24 96.00 25 100.00

q34

Cumulative Cumulative
q34 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 9 36.00 9 36.00
yes 16 64.00 25 100.00

q35_1

Cumulative Cumulative
q35_1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
R1202.27 1 7.14 1 7.14
R126203.00 1 7.14 2 14.29
R16846.63 1 7.14 3 21.43
R2020.92 1 7.14 4 28.57
R21242.45 1 7.14 5 35.71
R23818.41 1 7.14 6 42.86
R26150.97 1 7.14 7 50.00
R30.87 1 7.14 8 57.14
R3218.84 1 7.14 9 64.29
R3922.58 1 7.14 10 71.43
R648.58 1 7.14 11 78.57
R7212.70 1 7.14 12 85.71
R98.04 1 7.14 13 92.86
don't know 1 7.14 14 100.00

Frequency Missing = 11

******************************************************************************************************

q35_2

Cumulative Cumulative
q35_2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
R220.08 1 33.33 1 33.33
R2843.79 1 33.33 2 66.67
R99.60 1 33.33 3 100.00

Frequency Missing = 22

191
 q36

q36 Frequency Percent

ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
NO SPECIFC PLAN 1 9.09
fridge failure 3 27.27
mark short dated stock with a red sticker 1 9.09
monitored by pharmacist assistant 1 9.09
no specific method 1 9.09
no system 1 9.09
not monitored regularly 1 9.09
red sticker on brazier bins indicating the short expiring date 1 9.09
short dated stock listed and send to other clinics 1 9.09

Frequency Missing = 14

******************************************************************************************************

q37

Cumulative Cumulative
q37 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
001010 1 5.88 1 5.88
040711 1 5.88 2 11.76
080511 1 5.88 3 17.65
130611 1 5.88 4 23.53
210711 1 5.88 5 29.41
220711 1 5.88 6 35.29
270511 1 5.88 7 41.18
270711 1 5.88 8 47.06
280311 2 11.76 10 58.82
300511 1 5.88 11 64.71
300611 1 5.88 12 70.59
no stock take 3 17.65 15 88.24
none 1 5.88 16 94.12
not conducted 1 5.88 17 100.00

Frequency Missing = 8

q38

Cumulative Cumulative
q38 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
14 days 22 88.00 22 88.00
2 - 3 weeks 1 4.00 23 92.00
7 - 14 days 1 4.00 24 96.00
7 days 1 4.00 25 100.00

q39

Cumulative Cumulative
q39 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
most of the time 5 20.00 5 20.00
sometimes 19 76.00 24 96.00
yes 1 4.00 25 100.00

******************************************************************************************************

192
 q40

Cumulative Cumulative
q40 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
contact pharmacy 25 100.00 25 100.00

q41

Cumulative Cumulative
q41 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
yes 25 100.00 25 100.00

q41_specify1

Cumulative Cumulative
q41_specify1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
for all meds 20 100.00 20 100.00

Frequency Missing = 5

q41_specify2

Cumulative Cumulative
q41_specify2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
for tracer medicines 12 100.00 12 100.00

Frequency Missing = 13

q41_to_whom

Cumulative Cumulative
q41_to_whom Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
district pharmacy 4 17.39 4 17.39
pharmacist 12 52.17 16 69.57
pharmacy 4 17.39 20 86.96
supervising pharmacist 3 13.04 23 100.00

Frequency Missing = 2

******************************************************************************************************

q42_1

Cumulative Cumulative
q42_1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 23 95.83 23 95.83
yes 1 4.17 24 100.00

Frequency Missing = 1

q42_2

Cumulative Cumulative
q42_2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 1 4.00 1 4.00
yes 24 96.00 25 100.00

193
 q42_3

Cumulative Cumulative
q42_3 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 1 4.00 1 4.00
yes 24 96.00 25 100.00

q42_4

Cumulative Cumulative
q42_4 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 20 80.00 20 80.00
yes 5 20.00 25 100.00

q42_5

Cumulative Cumulative
q42_5 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 5 20.00 5 20.00
yes 20 80.00 25 100.00

******************************************************************************************************

q42_6

Cumulative Cumulative
q42_6 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 18 72.00 18 72.00
yes 7 28.00 25 100.00

q43_ed

Cumulative Cumulative
q43_ed Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 25 100.00 25 100.00

q43_os

Cumulative Cumulative
q43_os Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
yes 25 100.00 25 100.00

q43_sfo

Cumulative Cumulative
q43_sfo Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 25 100.00 25 100.00

194
 q44

Cumulative Cumulative
q44 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 2 8.00 2 8.00
yes 23 92.00 25 100.00

******************************************************************************************************

q45_1

Cumulative Cumulative
q45_1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
district out of stock 24 96.00 24 96.00
no proper reorder levels 1 4.00 25 100.00

q45_2

Cumulative Cumulative
q45_2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
Not sufficient space 1 4.55 1 4.55
district stock out 1 4.55 2 9.09
don’t order enough 1 4.55 3 13.64
late submission of orders 1 4.55 4 18.18
missed ordering 1 4.55 5 22.73
more pt's new township opened 1 4.55 6 27.27
no bin cards 1 4.55 7 31.82
no reorder levels 4 18.18 11 50.00
no reviewing of reorder levels 1 4.55 12 54.55
not correct ROL 2 9.09 14 63.64
pt load INCREASED 1 4.55 15 68.18
pt referred from other clinics 6 27.27 21 95.45
reducing of order by district pharmacy 1 4.55 22 100.00

Frequency Missing = 3

******************************************************************************************************

q45_3

Cumulative Cumulative
q45_3 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
DO NOT ORDER TIMEOUSLY 1 5.88 1 5.88
don’t order in time 2 11.76 3 17.65
lack of space 2 11.76 5 29.41
no reorder levels 2 11.76 7 41.18
no stock count 1 5.88 8 47.06
not enough space to adhere to re-order level 1 5.88 9 52.94
nurses do not fill bin cards when assistant is not there 1 5.88 10 58.82
pt referred from other clinics 1 5.88 11 64.71
referral for meds to other clinics 1 5.88 12 70.59
reorder levels incorrect 1 5.88 13 76.47
seasonal changes 1 5.88 14 82.35
seasonal changes e.g antibiotic use increases in winter 1 5.88 15 88.24
storage not sufficient 1 5.88 16 94.12
unexspected pt load 1 5.88 17 100.00

Frequency Missing = 8

195
 q46

Cumulative Cumulative
q46 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
yes 22 100.00 22 100.00

Frequency Missing = 3

q47

Cumulative Cumulative
q47 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 11 50.00 11 50.00
yes 11 50.00 22 100.00

Frequency Missing = 3

196
APPENDIX 14:
SHAMIMA TAYOB: 2011 10:45 Wednesday, October 5, 2011 130
PROGRAM FILE SHAMIMA.sas *** DATA FILE DATA Shamima data.xlsx
TRANSPORT OFFICER
PRINTOUT NUMBER 1

The FREQ Procedure

q1

Cumulative Cumulative
q1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 4 100.00 4 100.00

q2

Cumulative Cumulative
q2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 4 100.00 4 100.00

q3_1

Cumulative Cumulative
q3_1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
close van 1 100.00 1 100.00

Frequency Missing = 3

q3_2

Cumulative Cumulative
q3_2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
car 4 100.00 4 100.00

q3_other

Cumulative Cumulative
q3_other Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
Golf 1 100.00 1 100.00

Frequency Missing = 3

******************************************************************************************************

q4

Cumulative Cumulative
q4 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
orders has to be split 3 75.00 3 75.00
sometimes 1 25.00 4 100.00

197
 q5

Cumulative Cumulative
q5 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
never 1 25.00 1 25.00
sometimes 3 75.00 4 100.00

q6

Cumulative Cumulative
q6 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
yes 4 100.00 4 100.00

q7

Cumulative Cumulative
q7 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 4 100.00 4 100.00

q8

Cumulative Cumulative
q8 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
always 1 25.00 1 25.00
never 1 25.00 2 50.00
sometimes 2 50.00 4 100.00

******************************************************************************************************
q9

Cumulative Cumulative
q9 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 4 100.00 4 100.00

q10_1

Cumulative Cumulative
q10_1 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
store manager 2 100.00 2 100.00

Frequency Missing = 2

q10_2

Cumulative Cumulative
q10_2 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
facility manager 2 100.00 2 100.00

Frequency Missing = 2

198
 q10_3

Cumulative Cumulative
q10_3 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
security 3 100.00 3 100.00

Frequency Missing = 1

******************************************************************************************************

q10_other

Cumulative Cumulative
q10_other Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
Pharmacist assistant 1 33.33 1 33.33
depend on who is available 1 33.33 2 66.67
nurses 1 33.33 3 100.00

Frequency Missing = 1

q11

Cumulative Cumulative
q11 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
seldom 1 25.00 1 25.00
sometimes 3 75.00 4 100.00

q12

Cumulative
Cumulative
q12 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
boxes are left outside with security. If pharmacist 1 33.33 1 33.33
assistant iS available boxes are counted
boxes are seldom counted 1 33.33 2 66.67
depending on who is available, sometimes the number of 1 33.33 3 100.00
boxes are counted, At other times boxes are left outside
dorr at clinic without being checked

Frequency Missing = 1

q13

Cumulative Cumulative
q13 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
yes 4 100.00 4 100.00

******************************************************************************************************

199
 SHAMIMA TAYOB: 2011 10:45 Wednesday, October 5, 2011 134
PROGRAM FILE SHAMIMA.sas *** DATA FILE DATA Shamima data.xlsx
TRANSPORT OFFICER
PRINTOUT NUMBER 1

The FREQ Procedure

q14

Cumulative Cumulative
q14 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 4 100.00 4 100.00

q15

q15 Frequency Percent

ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
If number of boxes do not correspond district pharmacy is contacted 1 33.33
No adion most of the time orders are not checked 1 33.33
Order left at clinic. It is not checked most of the time during delivery 1 33.33

Frequency Missing = 1

q16

Cumulative Cumulative
q16 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 3 75.00 3 75.00
sometimes 1 25.00 4 100.00

q17

Cumulative Cumulative
q17 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
no 2 50.00 2 50.00
sometimes 2 50.00 4 100.00

q18

Cumulative Cumulative
q18 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
NOT SURE 1 25.00 1 25.00
yes 3 75.00 4 100.00

******************************************************************************************************

q19

Cumulative Cumulative
q19 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
always 2 50.00 2 50.00
sometimes 2 50.00 4 100.00

200
 q20

Cumulative Cumulative
q20 Frequency Percent Frequency Percent
ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ
N/A 1 50.00 1 50.00
do not report 1 50.00 2 100.00

Frequency Missing = 2

201